The choice of Attention Deficit and Hyperkinetic Disorders as the subject for the first SIGN guideline on a child and adolescent psychiatric disorder is a reflection of the continuing controversy surrounding these relatively common childhood behavioural disorders. The constellation of symptoms which make up Attention Deficit Hyperactivity Disorder2 (ADHD) and Hyperkinetic Disorder3 (HKD) are the most widely researched in child and adolescent psychiatry, but in spite of this there continues to be a lack of consensus regarding the definition of these disorders and their management.
The core symptoms of ADHD and HKD have a significant impact on a child's development, including social, emotional and cognitive functioning, and they are responsible for considerable morbidity and dysfunction for the child or young person, their peer group and their family. The secondary effects of ADHD and HKD can be extremely damaging. Affected children are often exposed to years of negative feedback about their behaviour and suffer educational and social disadvantage. These disorders are, in many cases, persistent. It is estimated that up to two thirds of children affected by hyperactivity disorders continue to have problems into adulthood.4 Professionals must therefore be concerned with the identification and treatment of ADHD and HKD and their secondary effects.
ADHD and HKD present a challenge to professionals from a variety of backgrounds, including general practitioners, health visitors, teachers, psychologists, psychiatrists, paediatricians and social workers. To date, management has been made more difficult by the various professionals involved working in isolation. Similarly, research into this complex constellation of symptoms has tended to follow single cause models with a resulting lack of integration of themes.
1.2 Need for a guideline
Hyperactivity is represented in the general population as a continuum. The distinction between normality and abnormality is subjective and arbitrarily defined. The core symptoms of ADHD and HKD can be considered to be an extreme of normal behaviour. In addition, children and young people suffering from several other emotional and behavioural disorders may show symptoms of ADHD and HKD.
Considerable controversy therefore surrounds the extent of these disorders, for which there are, as yet, no robust diagnostic tests; thus their definition continues to be debated. This in turn has led to wide variation in practice, with some affected children going undiagnosed and untreated and, in other cases, unaffected children being treated needlessly. Issues of co-morbidity and potential subtypes further cloud the picture. The available evidence suggests that the constellation of symptoms recognised as ADHD and HKD is valid. Causation remains unclear but the evidence for a biological basis appears to be converging. The evidence for a genetic contribution is strong but other factors are also likely to be important.
Partly as a result of the lack of clarity regarding the cause of ADHD and HKD, there is considerable variation in treatment. There is a lack of consensus about the use of psychostimulants, psychosocial, educational and other interventions or combinations of interventions. However, it is recognised that ADHD and HKD cause considerable morbidity and should be treated.
The use of psychostimulants remains controversial and there are concerns about prescribing such medication to children. Further anxieties surround the potential for inappropriate prescription, abuse and release onto the black market.
In light of these controversies and concerns there is an urgent need for an evidence-based guideline for clinical practice.
1.3 Aim of the guideline
The overall aim of this national guideline is to provide a framework for evidence-based assessment and management of ADHD/HKD, from which locally appropriate multidisciplinary approaches can be developed.
This guideline presents an appraisal of the existing evidence for the management of children and young people presenting with ADHD/HKD. Sections 1 and 2 of the guideline present an introduction to the disorder, including a discussion of the definition of ADHD/HKD and information on prevalence, co-morbidity and diagnostic criteria. Section 3 considers different assessment modes, including initial assessment and various types of specialist assessments. Sections 4 and 5 discuss the management of the disorder using both pharmacological and non-pharmacological interventions. Section 6 identifies a range of resources which may be of help to children and young people with ADHD and their families.
Many aspects of management, including the use of dietary and complementary therapies, have not been subject to systematic evaluation and therefore are not commented on in this guideline. The British Psychological Society has addressed the issue of multidisciplinary practice in the management of ADHD in their recent document Attention Deficit/Hyperactivity Disorder: Guidelines and principles for successful multiagency working.5
All health care professionals with either direct or indirect involvement in child health care must be aware of ADHD/HKD and the management options available. Continuing professional development is essential to ensure that new developments are implemented.
1.4 Statement of intent
This guideline is not intended to be construed or to serve as a standard of medical care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient and the diagnostic and treatment options available. However, it is advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.
1.5 Review and updating
This guideline was issued in 2001 and will be considered for review in 2003, or sooner if new evidence becomes available. Any updates to the guideline in the interim period will be noted on the SIGN website: www.sign.ac.uk.
Last modified 3/7/01
© SIGN 2001-2005