Attention deficit hyperactivity disorder (ADHD)

131 Pages·2015·0.99 MB·English

NATIONAL INSTITUTE FOR HEALTH AND CARE
EXCELLENCE
Centre for Clinical Practice – Surveillance Programme
Recommendation for Guidance Executive
Clinical guideline
CG72: Attention Deficit Hyperactivity Disorder (ADHD): The NICE guideline on diagnosis and
management of ADHD in children, young people and adults

Publication date
August 2008

Previous review dates
August 2011
Surveillance report for GE
February 2015

Surveillance recommendation
GE is asked to consider the proposal to update the following clinical question in the guideline
using the Standing Committee for Updates via the Clinical Guidelines Update Team:
1. Dietary interventions:
o What is the clinical and cost-effectiveness of elimination/restriction diets in
children with ADHD?
o What is the clinical and cost-effectiveness of dietary supplements (n-3
polyunsaturated fatty acid) in children with ADHD?
2. Pharmacological treatment:
o What pharmacological treatments are clinically and cost-effective for children
and young people with ADHD whose response to methylphenidate is
inadequate?
o What pharmacological treatments are clinically and cost-effectiveness for
adults with ADHD whose response to methylphenidate is inadequate?

It is noted that area 2 for pharamacological intervetions will proceed as a CGUT update
subject to the necessary permissions from the Department of Health and manufacturer.

GE is asked to consider the proposal to update the following clinical questions in the guideline
using the Standard Update process:
3. For people with ADHD, do psychological interventions:
o Cognitive behavioural therapy (CBT)
o Behavioural approaches / parent (effectiveness) training
o Multimodal interventions
other approaches:
o biofeedback
o physical therapies (relaxation etc.)
o other approaches
when compared to:
o no intervention

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o waiting lists
o ‘standard care’
o other psychological interventions
o medication for ADHD produce harm/benefits on the desired outcomes
and does this depend on:
o ADHD subtype
o associated disorder
o social context
o age
o gender
o severity delivery systems?

4. Is there evidence of the added value in terms of benefits/harm from combined
treatment (medication for ADHD plus psychological interventions)?

5. For people with ADHD, does drug treatment
o methylphenidate (including modified-release preparations)
o atomoxetine
o dexamphetamine
o tricyclic and other antidepressants
o bupropion
o nicotine (as skin patches)
o atypical antipsychotics
o modafinil
o clonidine
when compared to:
o waiting lists
o placebo
o other drug (head to head trials)
o psychological interventions
o parent training
produce harm/benefits on the desired outcome (ADHD symptoms/ associated mental health
problems/peer relationships/school learning and progress/family relationships/quality of
life/care needs, self-esteem) and does this depend on:
o ADHD subtype
o associated disorder
o social context
o age
o gender
o severity
o delivery systems (group/individual, family/group of families, manualised or
not, student versus specialist, rater)?

GE are asked to note that this ‘yes to update’ proposal will not be consulted on.

Key findings

Potential impact on guidance
Yes No
Evidence identified from Evidence Update 
Evidence identified from literature search 
Feedback from Guideline Development Group 

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Anti-discrimination and equalities considerations 

Feedback from Triage Panel meeting 
No update CGUT update Standard Transfer to static list Change review cycle
update
 

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NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE
Centre for Clinical Practice – Surveillance Programme
Surveillance review of CG72: ADHD

Recommendation for Guidance Executive
Background information
Guideline issue date: 2008
3 year review: 2011 (no update)
6 year review: 2014

NCC: Mental Health

Outcome of 6 year surveillance review
1. The Evidence Update on CG72: ADHD (published July 2013) was used as a source of evidence for this surveillance review that
considered new evidence since the guideline was previously reviewed in 2011. No new evidence that would impact on the guideline
recommendations was identified in the Evidence Update. An additional literature search for systematic reviews was carried out
between February 2013 (the end of the search period for the Evidence Update) and October 2014 and relevant abstracts were
assessed. Clinical feedback on the guideline was obtained from 9 members of the GDG through a questionnaire. The majority of the
GDG (5 out of 6) who responded to the question on the need to update the guideline indicated that they felt that there was sufficient
new evidence to warrant an update in a number of areas relating to treatment of ADHD.

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Outcome of 3 year surveillance review
2. A 3 year surveillance review (2011) concluded that there was no new evidence that would impact on the guideline recommendations.

3. New evidence that may impact on recommendations was identified relating to the following areas within the guideline:

Clinical area 1: Psychological and combined interventions 1.5.1-1.5.3
Q: For people with ADHD, do psychological interventions:
o Cognitive behavioural therapy (CBT)
o Behavioural approaches / parent (effectiveness) training
o Multimodal interventions
other approaches:
o biofeedback
o physical therapies (relaxation etc.)
o other approaches
when compared to: no intervention, waiting lists, ‘standard care’, other psychological interventions, medication for ADHD produce harm/benefits on
the desired outcomes* and does this depend on: ADHD subtype, associated disorder, social context, age, gender, severity delivery systems (group /
indiv., family / group of fam., manualised or not, student vs. specialist rater)?
Evidence summary GDG/clinical perspective Impact
3-year review (2011) Feedback from the Potential impacts on guideline
Neurofeedback questionnaire stated that recommendations.
clinically too much emphasis
Neurofeedback was more clinically effective in improving parent
was made initially on the NICE CG72 recommends parent-
and teacher ratings than computerised attention skills training in a
benefits of behavioural training/educational programmes for parents
RCT of children with ADHD.1 A 6 month follow-up of this study
interventions on the core or carers of pre-school children, and (group-
indicated that the improvement persisted2.
symptoms of ADHD in based) for parents of children and young

moderately severe cases which people of school age with ADHD and
Three RCTs were identified focusing on neurofeedback for control
may have inhibited use of moderate impairment as a first line treatment.
of ADHD symptoms, which is a new intervention not currently
medication.
recommended by the guideline. However, feedback from the GDG
Clinical feedback and evidence from 2
indicated that this treatment is fairly experimental at the moment
In addition new evidence was systematic reviews have highlighted doubts
and currently has restricted use in the UK. Therefore, it may be
highlighted through clinical over the effectiveness and use of parental
pertinent to await further evidence, particularly on the benefits,

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harms and cost-effectiveness of this treatment, before an update feedback that indicated the training for ADHD16, 20. Whilst other studies
is commissioned. This area will be factored into the future reviews effectiveness of behavioural indicate that this is an effective approach, this
of this guideline. therapies and the reported effect appears to be based on the rater status and
sizes from previously published whether they are blinded or not to the
Behavioural/parental training studies were in doubt. It was intervention. The evidence suggests that
One RCT in adults with ADHD suggested a beneficial reduction in suggested that this means that parental training may bring some benefits for
ADHD symptoms could be achieved with dialectal behavioural the revision of recommendations parents, but appears to have little impact on
therapy compared to a discussion group.3 concerning behavioural ADHD symptoms and behaviour outside the
therapies may be required. home. As such it may be appropriate to
One RCT assigned mothers of children with ADHD to a waitlist Cited as evidence to support reassess the benefit of this approach as first
control group, a traditional behavioural parent training programme this suggestion was the recent line treatment option.
or an enhanced behavioural parent training programme.4 A systematic review16 (identified
beneficial effect of participating in the parent training programmes by the Evidence Update 2013)
was observed although treatment gains were not maintained. which found that parent training
interventions are not effective
One RCT was identified which compared a standard behavioural for ADHD symptoms, when
parent training programme with a Coaching Our Acting-Out assessed using ‘probably
Children: heightening essential skills programme in fathers of blinded’ assessments. Given
children with ADHD.5 Improvements in both groups on measures that the 2008 guidelines
of child behaviour were observed by parents. recommended these
interventions as first line, based
The efficacy of the Incredible Years Basic parent training on cost-effectiveness modelling,
programme for families with children with ADHD was assessed in these recommendations are
an RCT.6 Compared with a waitlist control group the intervention likely to require reviewing.
group was associated with significantly lower levels of parent-
reported inattention and hyperactive/impulsive difficulties. In addition the GDG feedback
indicated that there are more
One RCT compared Parent-Child Interaction Therapy (PCIT) with publications reporting outcomes
waitlist control in families of preschool children with ADHD.7 The of CBT in adults (references not
PCIT was found to be an efficacious intervention. specified), and in particular 1
RCT (outside of review dates)
The efficacy of the revised new forest parenting programme which reported that use of

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(NFPP) compared with treatment as usual in treating ADHD in medication did not significantly
preschool children (n=41) was assessed in a RCT.8 The results improve outcomes over and
indicated that the NFPP had a positive effect on ADHD above use of CBT and placebo.
symptoms. It was indicated that this could
lead to an amendment of the
A RCT for children (n=94) with ADHD concluded that behavioural recommendation for first line
parental training compared to usual care was more effective in treatment for adults being
children with no or single-type comorbidity as assessed by medicated.
parents9.

For behavioural training, new evidence was identified which
indicated a beneficial effect of the training programmes evaluated.
However, the studies compared different behavioural training
interventions where the content is likely to differ and focused on
different age groups (preschool children, school children and
adults with ADHD). As such, there is insufficient new evidence in
this area to update the guideline recommendations on
psychological interventions and parent training.

One RCT was identified which evaluated the effectiveness of
behavioural parent training (BPT) as an adjunct to routine clinical
care (RCC) compared with RCC alone.10 Improvements were
observed in both groups. Specifically BPTplus RCC led to a
decrease in behavioural and internalising problems although no
differences between groups were observed for ADHD symptoms.

CBT
One RCT was identified which compared CBT with relaxation and
education support in adults with ADHD.11 The results of the study
indicated that lower post treatment scores on both the Clinical
Global Impression scale and the ADHD rating scale were
observed in the CBT group. In addition, self-reported symptoms

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were also significantly improved for CBT.

An RCT evaluated the efficacy of a 12-week manualised meta-
cognitive therapy group intervention compared with supportive
therapy in adults with ADHD.12 Improvement in dimensional and
categorical estimates of severity of ADHD symptoms was
observed in the meta-cognitive therapy group compared with
supportive therapy.

The results of the studies relating to CBT in adults with ADHD are
supportive of the current guideline recommendation.

Others
A Cochrane systematic review (including 4 studies, n=83)
assessed the effectiveness of meditation therapies for ADHD.
However only 1 study provided data for analysis. This data
indicated no beneficial effect of meditation for individuals with
ADHD.13

A RCT evaluating the efficacy of the First Step to Success
intervention for adolescents with ADHD was identified.14 The
programme had a beneficial effect for some aspects including
disruptive behaviour symptoms and social functioning but
intervention effects on the home-based assessments of problem
behaviours were not significant.

Evidence Update (2013)
Behavioural /Parental training
A Cochrane review (including 5 studies) evaluated the
effectiveness of parent training interventions in reducing ADHD
symptoms and associated problems in children and young people

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was identified15. The meta-analysis for child externalising
behaviour found no effect of parent training. Whereas the meta-
analysis for child internalising behaviour found an effect of parent
training. Likewise the meta-analysis of parenting skill changes
following parent training found a change in parental perception of
child behaviour, assessed using the Parenting Stress Index. The
authors concluded that this evidence was not strong enough to
form a basis for clinical practice guidelines.

A systematic review on behavioural interventions that included
parent training (8 studies), combination of parent and child
training (4 studies), combination of parent, child and teacher
training (2 studies) and child training only (1 study) indicated that
these interventions were effective when all studies were included
in the meta-analysis16. However, this was not the case when
restricted to the 7 studies with probably blinded assessments.

A pooled analysis of 3 RCTs for telephone delivery of parent
training (12 weekly 40min calls) or usual care (no intervention) for
the parents of children with ADHD (n=72, aged 8–12 years),
oppositional defiant disorder or anxiety was highlighted17.
Parent’s assessment of benefit which was not apparent after
completion of training but was apparent after 6 months or 1 year
post training.

Two RCTs in children with ADHD (n=47-158) that have
investigated behavioural interventions to improve organisational
skills both indicate that this approach improves organisation
compared with the control group18,19 . Both RCTs indicate that the
effect persisted after either 3 month or 2 year follow up.

6-year Surveillance review (2014)

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Behavioural/parental training
A systematic review (including 32 trials) on behavioural
interventions in children with ADHD across multiple outcome
domains was identified 20. For assessments made by individuals
closest to the treatment setting (usually unblinded), there were
significant improvements in parenting quality, parenting self-
concept and child ADHD, conduct problems, social skills and
academic performance seen with behavioural interventions.
However, with probably blinded assessments, significant effects
persisted only for parenting and conduct problems.

A systematic review which included 4 studies suggests mixed
findings regarding the benefit of Cogmed Working Memory
Training (CWMT) for youths with ADHD21.

A systematic review of 8 meta-analyses assessing
pharmacological and psychosocial interventions for adults with
ADHD indicates that no conclusions about the impact of
psychosocial interventions can be drawn based on meta-analyses
so far22.
Q: Is there evidence of the added value in terms of benefits/harm from combined treatment (medication for ADHD plus psychological interventions)?
medication for ADHD + psychological intervention vs. medication for ADHD only
medication for ADHD + child psychological intervention vs. medication for ADHD + parent-training intervention
medication for ADHD + psychological intervention vs. psychological intervention
parent-training + child psychological intervention (or multimodal psych intervention) vs. medication for ADHD (recommendations 1.5-1.7)
Evidence summary GDG/clinical perspective Impact
3-year review (2011) No GDG feedback was provided Potential impact on guideline
A meta-analysis was identified which compared methylphenidate, by the GDG questionnaire. recommendations.
psychosocial treatments and their combination for treatment of
ADHD.23 The results of the meta-analysis indicated that both New evidence has been identified at the 6

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