Children aged under five should not be offered drug treatment for attention deficit hyperactivity disorder (ADHD), and drugs should not be the first option for school-age children - except for those with severe ADHD, for whom medication is the best treatment, says the National Institute for Health and Clinical Excellence (NICE).

No patient with ADHD should offered antipsychotic drugs, adds NICE, in a newly-published guideline on the diagnosis and management of children, young people and adults with the condition.

In school-age children and young people with severe ADHD, the first-line treatment should normally be the modified-release form of methylphenidate (Novartis’ Ritalin, among other brands), provided they do not have any other serious mental health problems or if they also have conduct disorder, says the guideline. Methylphenidate or Eli Lilly’s Strattera (atomoxetine) should normally be used if the person also has tics, Tourette’s syndrome or anxiety, or if they are misusing stimulants.

If methylphenidate has been tried and does not help, Strattera should be offered, the guidance continues. Methylphenidate is usually the first treatment offered to adults with the disorder, and dexamfetamine is another option, it adds.

ADHD is estimated to affect up to 3% of school-age children and young people in the UK and about 2% of adults worldwide, says NICE, which notes that it is “an extremely distressing disorder, affecting the person as well as their families and carers.”

“In an ordinary comprehensive of around 1,400 children, there can be up to 30 children with ADHD,” commented consultant psychiatrist Tim Kendall, who is joint director of the National Collaborating Centre for Mental Health.

A key recommendation of the guideline calls on local National Health Service (NHS) organizations to ensure that specialist ADHD teams develop age-appropriate training programmes for professionals who have contact with people with ADHD, in order to help them diagnose and manage the condition. For children with ADHD, parent training/education programmes should be offered as first-line treatment, it adds, and stresses that, for all patients, drug therapy should always form part of a comprehensive treatment plan that includes psychological, behavioural, educational and occupational advice and interventions.

The guidance is the first to address the diagnosis and management of ADHD within both clinical and education settings, noted NICE’s deputy chief executive, Dr Gillian Leng, who was executive lead for the guidance, “At its heart is the recognition of the importance of establishing a multidisciplinary team, including the person with ADHD, their family and their teachers,” she said.

Dr Nicola Salt, a general practitioner (GP) who served on the Guideline Development Group member added that the guideline will help to increase GPs’ awareness of ADHD and give clear guidance on when it is appropriate to refer to specialist ADHD teams for formal diagnosis. “It also stresses the importance of good teamwork and shared care agreements with ADHD specialists in ongoing drug prescribing and monitoring of stable patients,” she said.

Another Group member, education specialist Dr Christine Merrell, suggested that the Department for Children. Schools and Families should consider enhancing the education of trainee teachers so that they are better able to recognise the signs and symptoms of ADHD.