Intended for healthcare professionals

Letters NICE guidance on ADHD

NICE recommendations are not evidence based and could expose many to unnecessary harm

BMJ 2008; 337 doi: (Published 28 October 2008) Cite this as: BMJ 2008;337:a2284
  1. Sami Timimi, consultant child and adolescent psychiatrist1,
  2. Jon Jureidini, consultant child and adolescent psychiatrist2,
  3. Jonathan Leo, associate professor of neuroanatomy3
  1. 1Lincolnshire Partnership Foundation NHS Trust, Lincoln LN4 2HN
  2. 2Women’s and Children’s Hospital, Adelaide, Australia
  3. 3Lincoln Memorial University, Harrogate, USA
  1. stimimi{at}

    The National Institute for Health and Clinical Excellence’s (NICE’s) single most important recommendation is for medication to be used as a first line treatment in “severe” attention-deficit/hyperactivity disorder (ADHD).1 Like other systematic reviews of ADHD medication treatment, NICE notes the inadequate reporting of study methodology, possible bias, limited reliability of results, and inadequate data regarding adverse events, correctly concluding that the evidence does not support using medication as a first line treatment for mild or moderate ADHD. Yet NICE concludes that medication should be used as a first line treatment in “severe” ADHD, with only one reference cited in support of this2 (which is a reanalysis of the data from the largest trial comparing medication and behavioural treatments), which concludes that the more severe subgroup showed a larger decrease in symptoms with medication than with behaviour therapy. However, these data were gathered 14 months after the beginning of the study. Swanson et al, analysing the same group of patients after 36 months, could not find support for long term benefits of medication over behaviour therapy, even in those with more severe symptoms.3

    These guidelines are likely to expose many children and adults to unnecessary harm. The recommendations are not supported by the evidence analysed by NICE. The evidence should lead to the conclusions that ADHD is a disorder of questionable validity, particularly as a diagnosis for adults, and use of medication should be a “research only” recommendation.


    Cite this as: BMJ 2008;337:a2284


    • Competing interests: Sami Timimi was invited to give evidence to a one day conference organised by NICE ADHD Guidelines development group, and has commented on earlier drafts of the guideline. Jonathan Leo was a peer reviewer for the first draft of the NICE ADHD guidelines, examining the “validity” of ADHD.