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Adult attention deficit hyperactivity disorder (ADHD) practice guidelines

Clinical guideline Last updated: May 2012 Published in Australia

Rather than develop its own clinical practice guidelines on this topic, the RANZCP convened a panel of specialists to review and recommend particular external guidelines.

These are the practice guidelines the RANZCP considers most appropriate for use by Australian and New Zealand psychiatrists for the treatment of adult ADHD.

The core components of these guidelines relating to carers and consumers are:

Key points and considerations when using the guidelines

Expert panel discussion

In this video, Dr Mark Kneebone and Dr Rosemary Edwards discuss the review process and provide guidance on the use of two selected guidelines.

Key clinical points

  • The two chosen guidelines provide useful information for the treatment of adults experiencing ADHD and should be used as a general guide for appropriate practice, subject to the clinician’s judgement.
  • Treatment of ADHD must include comprehensive assessment and a management/treatment plan.
  • Consideration should be made for psychiatrists who are practicing in isolation without appropriate access to training, support and supervision.

Assessment

  • Information on the diagnosis of ADHD:
    • NICE guideline section 1.3 Diagnosis of ADHD (p. 20).
    • CADDRA guideline Chapter 1: Diagnosis and Overview of Visits (p. 1); Chapter 2: Differential Diagnosis and Comorbid Conditions (p. 9).
    • CADDRA guideline Chapter 5: Specific Issues in the Management of ADHD in Adults (p. 29) provides additional useful information.
  • The DSM-IV criteria are the minimum necessary for diagnosis of ADHD.
  • A discussion with partners and family members about problems specifically related to ADHD symptomatology should also form part of the assessment process.

Management

  • Information is a key component of the management plan. Consumers and carers should be provided with information about ADHD and the treatments available.
  • An individual management plan should be collaboratively developed between individuals and carers.

Treatment

  • A multimodal approach is recommended for treatment of ADHD. This may include medication, psychosocial management strategies and, where appropriate, educational interventions. Information regarding psychosocial and educational interventions can be found in the CADDRA guideline, Chapter 6: Psychosocial Interventions and Treatments (p. 39).
  • As part of the treatment plan, patients should have their blood pressure and weight monitored.
  • The issue of comorbidity becomes very important when it comes to prioritising treatment. Each comorbid condition often requires treatment in its own right. In most instances including substance abuse disorders, bipolar disorder and severe mood disorders, the comorbid condition may need to first be stabilised prior to commencing treatment for ADHD. Information regarding comorbid disorders can be found in the CADDRA guideline Chapter 2: Differential Diagnosis and Comorbid Disorders (p. 9).

Medication

  • The NICE guideline recommends drug treatment as the first-line treatment for adults with ADHD with either moderate or severe levels of impairment. Methylphenidate is the first-line drug. Further advice on treatment can be found in section 1.7, Treatment of Adults with ADHD (p. 36).
  • Medication is typically indicated when the ADHD symptoms and associated impairment is moderate to severe. As mentioned previously, medication is just one part of a multimodal treatment approach.
  • Further information on pharmacological treatment can be found in the CADDRA guideline, Chapter 7: Pharmacological Treatment of ADHD (p. 55).
  • Important issues for consideration include legislation on the prescription of psychostimulants.
    NB: In some states a second psychiatric opinion is required if doses of more than 60 mg a day of methylphenidate or 30 mg a day of dexamphetamine sulphate are prescribed.
  • Further guidance on the use of stimulant medications in adults can be found in the RANZCP Professional Practice Guideline 6

Guideline review process

A panel of specialists reviewed a number of guidelines for the treatment of ADHD using the AGREE instrument (Appraisal of Guidelines for Research and Evaluation).

The panel of specialists comprised:

  • Professor Mark Oakley Browne (TAS)
  • Dr Rosemary Edwards (Wellington)
  • Dr Oleh Kay (WA)
  • Dr Mark Kneebone (NSW)

The Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder, 2009 (available on the NHMRC’s website) were reviewed, and were identified as the most comprehensive and appropriate for inclusion on the RANZCP's list of endorsed guidelines. However, in view of the unresolved conflict-of-interest investigations against three Harvard Medical School researchers, whose work is heavily cited throughout the draft guidelines, the NMHRC has not endorsed these guidelines. The panel shared this concern and therefore did not recommend the guidelines for inclusion in the suite of RANZCP-endorsed guidelines.

Approved by RANZCP General Council: 18 August 2012.

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Disclaimer

NICE disclaimer: Clinical Guideline 72 was issued by the National Institute for Health and Clinical Excellence (NICE) in September 2008. NICE guidance is prepared for the National Health Service in England and Wales. NICE guidance does not apply to Australia and New Zealand and NICE has not been involved in the development or adaptation of any guidance for use in New Zealand and Australia.