Commentary: Controversies in NICE guidance on attention-deficit/hyperactivity disorderBMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a1466 (Published 24 September 2008) Cite this as: BMJ 2008;337:a1466
- Anne Thompson, consultant child and adolescent psychiatrist
In 2002 both attention-deficit disorder and hyperactivity appeared in a list of human problems that BMJ readers believed were “non-diseases.”1 In producing its third and most comprehensive synthesis of research, clinical consensus, and economic analysis on attention-deficit/hyperactivity disorder (ADHD),2 the National Institute for Health and Clinical Excellence (NICE) will no doubt fuel the controversy about the nature of ADHD.
The full report of the NICE guidance acknowledges the social scientific paradigm that casts doubt on the utility and appropriateness of ADHD as a diagnostic category. The report goes on to examine the diagnosis of ADHD and concludes it is a valid concept. Persistent sceptics will read sobering accounts from both research and personal testimony of the impairment experienced by hyperactive people, including the iatrogenic impairment resulting from professional ignorance and disbelief.
If those who purchase services fund fully NICE’s recommendations for a stepped care approach to managing childhood ADHD and for ubiquitous mental health care for the estimated 3% of adults with ADHD, then clinical services will look quite different from the current inadequate and varied provision. NICE rightly says that full implementation of the guidance will take time. It sets out a bold vision of improvement in both child and adult services.
The guidance moves the recognition and initial management of childhood ADHD out of secondary care clinics and into the broad range of universal and targeted children’s services slowly developing in NHS trusts and local authorities. It proposes that these services should offer evidence based parent training programmes to all families who have a child with ADHD. The use of this model of “comprehensive child and adolescent mental health services” as outlined in the Department of Health’s document The Mental Health And Psychological Wellbeing Of Children And Young People3 will be a stiff challenge to joint purchasing processes, which are still in their infancy.4
Community paediatricians and child and adolescent psychiatrists will find that much of the information about the assessment and medical management of children with severe ADHD is similar to previous international guidelines.5 6 The main positive impact of the guidance for children’s specialists seems to be that children with suspected ADHD should arrive at secondary care clinics having already had some assessment and intervention. More controversially, the existing multimodal, multiprofessional interventions which are assumed to be good practice in comprehensive child and adolescent mental health services are not supported by NICE’s economic evaluations. If guided by NICE’s assertion that group based parent training for all affected children and medication for severely impaired children are the two best treatments, future purchasing decisions may eventually reduce the breadth of specialist service provision for children with ADHD.
The inclusion of adult ADHD in the guidance will be welcomed by adults whose ADHD has previously gone unrecognised, misdiagnosed, or untreated. The guidance outlines services for diagnosis, medication management, and psychological intervention for adults while recognising that the current lack of training and service provision in adult mental health services is a major impediment to implementation. NICE recommends prescribing methylphenidate as first line treatment, and many adult psychiatrists may be initially reluctant to do this. While psychostimulants have been used in children for 70 years, methylphenidate is not licensed for adults. Service purchasers keen to set up new provision for adult ADHD should be wary of taking headlines about the NICE recommendations at face value: the assertion that psychological intervention for adults with ADHD is best delivered in a group format is based on a comparison of just two trials.
Interventions not endorsed for ADHD in the guidance are unlikely to cause much controversy: specifically not recommended are elimination diets, polyunsaturated fatty acid supplements, and antipsychotic drugs.
NICE charges local ADHD teams and multiagency groups with the task of training both health and education staff. Such training could usefully have been the subject of an economic analysis as it will be far from cost neutral. Changing professional thinking away from the “non-disease” model of ADHD will not be accomplished by single formal teaching sessions. Those who know ADHD, its morbidity, and the successes seen in treatment will need to work regularly alongside those who do not to bring about lasting changes in practice.
Cite this as: BMJ 2008;337:a1466
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.