Systematic review of national and international guidelines on attention-deficit hyperactivity disorder

Abstract

During the last few years several clinical guidelines on attention-deficit hyperactivity disorder (ADHD) have been published by national and international medical societies. To systematically review and compare recommendations of selected ADHD guidelines, we performed a systematic search in online guideline databases and PubMed in order to retrieve guideline texts. Guidelines meeting inclusion criteria were reviewed and recommendations on assessment and treatment extracted. The AGREE instrument was used to assess methodological quality. Of the 26 guidelines identified, 13 were selected for further analysis: 11 guidelines deal with ADHD in childhood and adolescence and 5 guidelines cover transitional patients and/or ADHD in adults. The methodological quality of ADHD guidelines is moderate to good. They reflect similarities and differences of healthcare systems. Diagnosis throughout the lifespan is based on a detailed clinical history. There is greater agreement on evidence-based pharmacological treatment than on psychosocial interventions, reflecting the strength of evidence.

Keywords

Attention-deficit hyperactivity disorder diagnosis guidelines therapeutics

Introduction

Attention-deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, with a worldwide prevalence estimated to lie between 0.85% and 10% in childhood and adolescence, and between 0.5% and 4.4% in adulthood (Fayyad et al., 2007; Ford et al., 2003; Kessler et al., 2006; Polanczyk et al., 2007). This wide range is unlikely to represent true differences in prevalence estimates across populations and is largely accounted for by methodological differences (Polanczyk et al., 2007). It is associated with a broad range of functional impairment and negative outcomes, resulting in a significant financial burden on families and society as a whole (National Institutes of Health, 2000; McGough, 2005). During their lifetime, patients with ADHD may present to a variety of medical services for assessment and treatment. The use of different diagnostic classification systems such as DSM-IV, ICD-10 and Wender-Utah criteria (American Psychiatric Association, 2000; Retz-Junginger et al., 2002; Ward et al., 1993; World Health Organization, 1992), the uncertainty of the reliability of child based criteria for adults, the high level of comorbidity and the risks of diversion and misuse of pharmacological treatments (McCabe et al., 2006; Wilens et al., 2006) present difficult challenges to practising clinicians.

Clinical guidelines have become an important instrument for evidence-based medical practice, better quality of care, resource allocation and cost-efficient service provision (Huttin, 1997). Guidelines have important limitations (Woolf et al., 1999) if their methodological quality is poor, if they are out of date, if they are biased or if they demand a standard of care that is not available. Over the last few years, several national and international medical societies, representing and targeting various groups of healthcare professionals, have published guidance on diagnosis and/or treatment of ADHD. Such guidelines initially focused on the child and adolescent population. More recently, guidelines specific to the adult population have also been published.

The aim of this review is to identify established standards and variations of practice in the assessment and treatment of ADHD, by comparing the recommendations of selected guideline documents according to predefined criteria, and assessing the methodological quality of the different guidelines for ADHD in children, adolescents and adults.

Methods

In order to identify the relevant guidelines, the US National Guideline Clearinghouse (www.guideline.gov), two German online databases (www.leitlinien.de and www.awmf.org, provided by the Association of the Scientific Medical Societies (AWMF)), the Australian National Health and Medical Research Council (www.nhmrc.gov.au), the New Zealand Guidelines Group (www.nzgg.org.nz), PubMed (www.pubmed.gov, search term ‘ADHD guideline’) and the Centre for Reviews and Dissemination of the University of York (www.crd.york.ac.uk, search term ‘ADHD’) were screened. Reference lists of retrieved guideline texts were screened for further documents.

To meet the inclusion criteria, the guidelines had to focus on assessment and/or management of ADHD and be produced by national or international medical societies, professional bodies or health ministries. Consensus statements, regional guidelines and local protocols were excluded. When an updated version had replaced a preceding guideline, the latest version was analysed. When an organization published complementary documents, such documents were considered to be representative of the whole of that organization’s recommendations.

Selected documents were compared according to predefined criteria regarding general information on the guideline and its development process, diagnostic recommendations and treatment recommendations, both pharmacological and psychosocial. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to measure and compare the methodological quality of all guidelines (AGREE Collaboration, 2003). It consists of 23 key items rated on a four-point Likert scale and is organized in six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. The sum of all domain scores gives the total score. These scores can be presented as a percentage of the maximum possible score for that domain or as maximum possible total score. There is a final section for overall assessment of the quality of the guideline in the instrument, based on each of the appraisal criteria. The authors received a standard instruction on how to use the AGREE instrument, through the AGREE Instrument Training Manual. The two reviewers performing the scoring (MS and UM) agreed upon a consensus rating for each item score in the case of initial differences.

Results

Guideline selection

Thirteen guidelines and practice parameters meeting the inclusion criteria were identified, representing the recommendations of ten different medical associations: the American Academy of Pediatrics (AAP, United States; 2000, 2001), the New Zealand Ministry of Health (NZ, New Zealand; 2001), theGerman Experts – Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN, Germany; 2003), the European Society for Child and Adolescent Psychiatry (ESCAP, Europe; 2004, 2006), the British Association of Psychopharmacology (BAP, United Kingdom; 2006), the American Academy of Child and Adolescent Psychiatry (AACAP, United States; 2002, 2007), the Deutsche Gesellschaft für Kinder und Jugendpsychiatrie und Psychotherapie (DGKJP, Germany; 2007), the National Institute for Health and Clinical Excellence (NICE, United Kingdom; 2008), the Scottish Intercollegiate Guideline Network (SIGN, United Kingdom; 2009) and the Canadian Attention Deficit Disorder Resource Alliance (CADDRA, Canada; 2011).

The initial search revealed 26 guideline texts. Three guidelines (Hayashi et al., 2006; Hvolby and Jørgensen, 2004; Saito, 2005) were excluded owing to language limitations (two from Japan and one from Denmark), and three guidelines were no longer valid (National Institutes of Health, 1998; NICE, 2006; Wong et al., 1999) as declared by the responsible medical society. Seven further retrieved guidelines were excluded from the study: four guidelines had a regional scope (Cincinnati Children’s Hospital Medical Center, 2004; Institute for Clinical Systems Improvement, 2010; Pliszka et al., 2006; University of Michigan Health System, 2005) and three others were not produced by a recognized medical society, professional body or health ministry (August and Realmuto, 2000; Kutcher et al., 2004; Roy-Byrne et al., 1997). It is uncertain whether the guidelines excluded based on language met the other inclusion criteria. Another guideline is being prepared by the Royal Australasian College of Physicians but was only available as a draft version and was awaiting approval by the Australian National Health and Medical Research Council at the time of concluding this paper (Figure 1).

Individual guidelines

AAP (2000, 2001)

This guideline was developed for primary care clinicians by the American Academy of Pediatrics (AAP) Committee on Quality Improvement, as part of AAP policy. The two parts address diagnosis and evaluation (AAP, 2000) and treatment (AAP, 2001) of uncomplicated cases of ADHD in 6–12-year-old children presenting in primary care. They are two of the oldest guidelines evaluated in this study. They advocate the recognition of ADHD as a chronic condition and the specification of appropriate target outcomes involving the clinician, child, parents and school. Although treatment suggestions include psychosocial and pharmacological interventions, bupropion, clonidine and tricyclic antidepressants are considered to be outside the scope of the guideline.

New Zealand Ministry of Health (2001)

In 2001 the New Zealand Ministry of Health produced a guideline for the assessment and treatment of ADHD in children and adolescents (New Zealand Ministry of Health, 2001). This document emphasises the incorporation of Maori cultural aspects in the assessment and treatment, including the need for appropriate training on cultural competence. Recommendations are based on published evidence and expert opinion, and highlight the need for a holistic approach by multidisciplinary teams. The guideline supports the appointment of a key worker or case manager in both primary and secondary care, in order to coordinate the assessments and subsequent treatment and ensure that treatment reviews are conducted in a timely way. The guideline states that it is responsibility of the New Zealand Ministry of Health to ensure that the recommendations are reviewed and updated every two years. It is unclear whether this has occurred.

DGPPN (2003)

This relatively short German guideline was published in 2003 by a group of experts representing the Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN). It is the first and only ADHD guideline that covers solely the adult population. Assessment is very much based on the Wender-Utah criteria. The development of this guideline is not described and, compared with other more comprehensive guidelines, this text has many methodological weaknesses. Nevertheless, it has increased awareness for this condition in German speaking countries (Ebert et al., 2003).

ESCAP (2004, 2006)

In 2004, the European Society for Child and Adolescent Psychiatry (ESCAP) produced the European clinical guidelines for hyperkinetic disorder (Taylor et al., 2004), an upgrade on a previous document dating from 1998, following discussions held at the European Network of Hyperkinetic Disorder (EUNETHYDIS). The upgraded guideline is evidence-based and consensus-driven and includes discussion of the diagnosis and treatment of pre-schoolers, children and adolescents. In 2006, this guidance was complemented by the publication of another document concerning the use of long-acting medications in hyperkinetic disorders (Banaschewski et al., 2006), which included a systematic review of published and unpublished studies, providing a summary of the effect sizes, normalization rates and numbers needed to treat for each of the long duration medications then on the market. German translations of both documents were published in 2008 (Banaschewski et al., 2008).

BAP (2006)

The British Association of Psychopharmacology (BAP) was the first association to produce guidelines on the diagnosis and management of ADHD inadults and adolescents in transition to adult services (Nutt et al., 2006). This document was produced in 2006 with plans for an updated version every five years and was sponsored by the pharmaceutical industry. The sponsors were invited to the meetings but did not contribute to the proceedings. The guidelines include considerations on prescribing in the United Kingdom, where stimulants are considered as controlled substances and where prescribing of stimulants for adults with ADHD was not licensed until 2011 and therefore considered ‘off label’.

DGKJP (2007)

This is the third revision of the ADHD guideline of the Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie (DGKJP), published both online and as a chapter in a book with child and adolescent psychiatry guidelines (DGKJP, 2007). This guideline is relatively detailed and explicit in recommending psychological testing for all patients and proposes a multimodal treatment programme with a hierarchy of individual components. The guideline reflects the relatively greater availability of hospital beds and day hospital placements in Germany. The guideline is methodologically weak because it is not referenced to an evidence base and does not specify the method of its development.

AACAP (2002, 2007)

The American Association of Child and Adolescent Psychiatry (AACAP) has produced two widely circulated guidelines: one on the use of stimulants across all ages (Greenhill et al., 2002) and another on assessment and treatment of ADHD in pre-schoolers, children and adolescents (Pliszka et al., 2007). The recommendations are based on available empirical evidence and clinical consensus. The practice parameter on ADHD was produced in 2007 and supersedes an earlier guideline.

NICE (2008)

The National Institute for Health and Clinical Excellence (NICE), an organization responsible for providing national guidance for the National Health Service (NHS) in England and Wales, published a thorough guideline covering the assessment and treatment of all patients from the age of 3 years (NICE, 2008). This guideline supersedes a technology appraisal addressing the use of methylphenidate, atomoxetine and dexamphetamine in child and adolescent ADHD (NICE, 2006). The guideline development process included a systematic search for published refereed studies, unpublished studies and grey literature. Key priorities are clearly defined both for diagnosis and treatment of children (over the age of 3 years), young people and adults with ADHD. The NICE guideline, with an important impact on public healthcare provision in England and Wales and extending its influence to other European and Commonwealth countries, makes differential recommendations for pharmacological treatment of ADHD. The guideline recommends that pharmacological treatment should only be first-line treatment in adults and in children and adolescents with severe (but not with moderate) impairment, and that it should always be part of a comprehensive treatment plan including psychological, behavioural and educational interventions. The guideline further recommends the creation of multidisciplinary specialist ADHD teams and/or clinics, multi-agency groups in every locality and training provisions for health professionals and teachers. Both documents have a clear cost-effectiveness analysis, addressing the impact of the recommendations on service provision and health economics. The fact that this guideline was produced by NICE has a major influence not only on care but also in its requirement for the NHS to provide age-appropriate services for all patients with ADHD.

SIGN (2009)

The Scottish Intercollegiate Guideline Network (SIGN), an organization equipped to develop and disseminate national clinical guidelines in Scotland, produced this guideline (SIGN, 2009), covering diagnosis and treatment of ADHD in children and adolescents. This replaces previous guidance from 2001 and an update from 2005. SIGN draws its recommendations from available evidence and from ‘good practice points’, defined as the recommended best practice based on the clinical experience of the guideline development group. Guidelines produced by SIGN have clear bearings on the policy and resource allocation by the NHS in Scotland.

CADDRA (2011)

Early in 2011 the Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA), updated its practice guidelines for specialists and primary care practitioners, published both in French and English. The guideline is organized according to the complexity of the presenting case. This document, available through the organization’s website (www.caddra.ca), provides a comprehensive number of assessment tools and templates for monitoring and for liaison with external agencies. The guideline was produced by a systematic process of review of the evidence and consensus meetings that included paediatricians, psychiatrists and general practitioners and had a declared objective to facilitate care in practice and training, and to standardize the delivery of care throughout the country. It introduces an online ADHD toolkit for primary care practitioners, providing a structured interview tool and free rating scales relevant for all age groups, with instructions for their use, making the assessment more congruent across age groups and enabling the condition to be managed in primary care to a greater degree.

Guideline comparison

The selected guidelines, published between May 2000 and January 2011, originate from five different countries (United Kingdom, United States, Germany, New Zealand and Canada) and one European group (Table 1). There were no significant differences in the conceptualization of the disorder across all guidelines. Eleven guidelines make recommendations for ADHD in childhood and adolescence. CADDRA and NICE cover ADHD from childhood to adulthood; ESCAP and AACAP contain brief comments on pharmacological treatment in adulthood; BAP covers both patients in transition from adolescent to adult services and adults; the DGPPN guideline only concerns ADHD in adulthood.

Table 1.

Overview of national and international ADHD guidelines

Association	AAP (2000^a, 2001^b)	NZ (2001)	DGPPN (2003)	ESCAP (2004^c, 2006^d)	BAP (2006)	DGKJP (2007)	AACAP (2002^e, 2007^f)	NICE (2008)	SIGN (2009)	CADDRA (2011)
Authors	Perris & Stein et al	Tuohy et al	Ebert et al	Taylor et al^c; Banaschewski et al^d	Nutt et al	Döpfner et al	Greenhill et al^e; Pliszka et al^f	Taylor et al	Forbes et al	Weiss et al
Date of publication	May 2000^a; Oct 2001^b	Jul 2001	Oct 2003	Jul 2004^c; May 2006^d	Nov 2006	Nov 2006	Feb 2002^e; Jul 2007^f	Sep 2008	Oct 2009	Jan 2011
Previous version	-	-	-	Dec 1998	-	1999; 2003	1997	Mar 2006	Jun 2001*	2006; 2008
Origin	USA	New Zealand	Germany	Europe	UK	Germany	USA	UK	UK (Scotland)	Canada
Source	www	www	Journal	Journal	www	www; book	www	www, book	www	www
Target group	Primary care clinicians	Health professionals	Physicians	CAMH, Paeds	GP, Paeds, CAMH, Psych	CAMH	Clinicians, CAMH, Psych	Clinicians	Health professionals	Physicians
Grading of evidence	Yes	No	Yes	Yes	Yes	Yes (inconsistent)	Yes	Yes	Yes	Yes
Funding	Unclear	Unclear	Self-funded; no individual disclosures	Unclear	Pharma	Unclear	Unclear; individual disclosures	Public funding	Public funding	Self-funded; with individual disclosures
Diagnosis	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Treatment	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
C&A	Yes	Yes	No	Yes	No	Yes	Yes	Yes	Yes	Yes
Adult	No	No	Yes (adults only)	Yes (drug treatment only, Banaschewski et al)	Yes	No	Yes (Greenhill et al)	Yes	No	Yes

*, updated in 2005; CAMH, child and adolescent psychiatrists; Paeds, paediatricians; Pharma, pharmaceutical industry; C&A, child and adolescent. AAP 2000 , American Academy of Pediatrics, Committee on Quality Improvement Subcommittee on Attention-Deficit / Hyperactivity Disorder (2000) Clinical Practice Guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder; AAP 2001, American Academy of Pediatrics, Commitee on Quality improvement, Subcommitee on Attention-Deficit/ Hyperactivity Disorder (2001) Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder; NZ 2001 , New Zealand Ministry of Health (2001) New Zealand Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder; DGPPN 2003 , Ebert D, Krause J, Roth-Sackenheim C (2003) ADS im Erwach senenalter - Leitlinien auf der Basis eines Expertenkonsensus mit Unterstützungder DGPPN; ESCAP 2004 , Taylor E, Döpfner M, Sergeant J, Asherson P, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Rothenberger A, Sonuga-Bark E, Steinhausen HC, Zuddas A (2004) European clinical guidelines for hyprkinetic disorder - first upgrade; ESCAP 2006 , Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, Döpfner M Faraone SV, Rothenberger A, Sargeant J, Steinhausen HC, Sonuga-Barke EJ, Taylor E (2006) Long-acting medications for the hyperkinetic disorders. A systematic review and European treatment guideline; BAP 2006, Nutt DJ, Fone K, Asherson P, Bramble D, Hill P, Matthews K, Morris KA, Santosh P, Sonuga-Barke E, Taylor E, Weiss M Young S; British Association for Psychopharmacology (2006) Evidence-based guidelines for management of attention deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology; DGKJP 2007, Deutsche Gesellschaft für Kinder-und Jugendpsychiatrie und Psychotherapie (2007) Hyperkinetische Störungen (F90). In Deutsche Gesellschaft für Kinder-und Jugendpsychiatrie und Psychotherapie (eds), Leitlinien zur Diagnostik und Therapie von psychischen Störungen im Säuglings-, Kinder- und Jugendalter 3. überarbeitete Auflage; AACAP 2002, Greenhill LL, Pliszka S, Dulcan MK, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S; American Academy of Child an Adolescent Psychiatry (2002) Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents and Adults; AACAP 2007, Pliszka S; American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder NICE 2008, National Institute for Health and Clinical Excellence (2008) Attention deficit hyperactivity disorder - Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72; SIGN 2009, Scottish Intercollegiate Guidelines Network (2009) Management of attention deficit and hyperactivity disorders in children and young people - A national clinica guideline; CADDRA 2011, Canadian Attention Deficit Disorder Resource Alliance (2011) Canadian ADHD Practice Guidelines, Third Edition.

Table 2 reviews the recommendations for assessment of ADHD. All guidelines support the use of categorical diagnostic criteria; most of them recommend the use of either DSM-IV or ICD-10. There is unanimous consensus about screening for comorbidities and the need for a physical examination to rule out medical causes of ADHD, to ensure that appropriate differential diagnoses, such as hearing deficits, have been considered, and to make sure that the patient does not have any medical contraindications to pharmacological treatment if indicated.

Table 2.

Recommendations for the assessment and diagnosis of ADHD

Association	AAP (2000, 2001)	NZ (2001)	DGPPN (2003)	ESCAP (2004, 2006)	BAP (2006)	AACAP (2002, 2007)	DGKJP (2007)	NICE (2008)	SIGN (2009)	CADDRA (2011)
Diagnostic criteria	DSM-IV	DSM-IV	ICD-10; DSM-IV; Wender-Utah criteria	ICD-10; DSM-IV	DSM-IV; ICD-10	DSM-IV; ICD-10	ICD-10; DSM-IV	DSM-IV; ICD-10	DSM-IV; ICD-10	DSM-IV
ADHD specialist	0	+	0	+	+	0	0	+	+	+
Screening	+	−	0	0	+	+	0	−	0	+
Screening for comorbidities	+	+	+	+	+	+	+	+	+	+
Psychiatric interview	Patient, parents, school, informants	Patient, parents, school, informants, observation	Parents,informants	Patient, parents, school	Patient,informants	Patient, parents, school	Patient, parents, school	Patient, informants	Patient, parents, school	Patient, parents, school, informants
Questionnaires and rating scales	Optional (CPRS-R, CTRS-R, SSQ-R); not recommended for diagnosis (CBCL-R, TRF, DSMD-total scale, CPRS-R-Global Problem Index, CTRS-R-Global Problem Index)	CPRS-R; CTRS-R; ACTeRS; SNAP-IV	DSM-IV symptom checklist; CPRS; WURS; BADDS	C-GAS; axis 6 of the MAS; CBCL; CCC; CPRS-R; CTRS-R; DBD; HSQ-R; SSQ-R; IOWA-CTRS; RBPC; Rutter Scales; SNAP-IV; SDQ; TRF; YSR; NIMH DISC-IV; PACS	WURS; ASRS; BADDS; BSOPA-SC; ASRS-V1.1; ADHDRS-IV; Canadian Consensus ScreeningChecklist	WPRS; WURS; CAARS; APRS; ADHDRS-IV; BADDS; CBCL; CPRS-R; CTRS-R; CASS-L; HSQ-R; SSQ-R; IOWA CTRS; SNAP-IV; SKAMP; VADPRS; VADTRS; CAP	not specified	Conners’ rating scales, CAADID, SDQ, C-GAS	+	CAAT
Neuropsychological assessment	0	Not routinely; continuous performance tests potentially useful.	0	+	Not for diagnosis; recommended to inform management	−	0	0	0	Psychoeducational assessment and psychological testing
Physical examination	+	+	+	+	+	+	+	+	+	+
Other investigations	Blood lead levels, thyroid function, brain imaging, EEG and continuous performance tests not routinely recommended	EEG, heavy metal tests, thyroid function tests, other blood tests and organ imaging tests not recommended routinely. Personality tests not recommended	EEG; thyroid function tests; CT/MRI	Not routinely	0	Thyroid function tests, serum lead levels, EEG, head MRI, SPECT, PET - all not routinely recommended	Thyroid function tests; EEG	ECG if clinical/historical indications	Blood analysis, EEG and brain imaging if necessary to exclude underlying medical problem	Polysomnography, EEG and brain imaging may be indicated

NR, no recommendation found; +, explicit favourable recommendation; −, negative recommendation; C&A- child and adolescent; CT, x-ray computed tomography; EEG - electroencephalogram; MRI - magnetic resonance imaging; PET, positron emission tomography; SPEC T, single photon emission computed tomography. ACTeRS, ADD-H Comprehensive Teacher Rating Scale; ADHDRS, ADHD Rating Scale; ASRS-V 1.1, Adult ADHD Self-Report Scale Screener; BADDS, Brown Attention Deficit Disorder Scale; BSOPA-SC, Barkley Self, Other and Past ADHD symptom checklist; CAADID, Conners Adult ADHD Diagnostic Interview for DSM-IV; CAARS, Conners’ Adult ADHD Rating Scale; CAAT, CADDRA ADHD Assessment Toolkit; CAP, Child Attention Problems rating scale; CASS, Conners-Well’s Adolescent Self-report Scale; CBCL, Child Behaviour Checklist; CCC, Children’s Communication Checklist; C-GAS, Children’s Global Assessment Scale; CPRS, Conners Parent Rating Scale; CTRS, Conners Teacher Rating Scale; DBD, Disruptive Behavior Disorder Checklist; DSMD, Devereaux Scales of Mental Disorders; HSQ-R, Home Situations Questionnaire; IOWA CTRS, Inattention/Overactivity With Aggression (IOWA) Conners Teaching Rating Scale; MAS, Multiaxial classification of child and adolescent psychiatric disorders, World Health Organization; NIMH DISC-IV, National Institute of Mental Health Diagnostic Interview Schedule for Children; PACS, Parental Account of Childhood Symptoms; RBPC, Revised Behavior Problem Checklist; SDQ, Strengths and Difficulties Questionnaires; SKAMP, Swanson, Kotkin Afler, M-Flynn and Pelham scale; SNAP-IV, Swanson, Nolan and Pelham scale; SSQ, School Situations Questionnaire; TRF, Teacher Report Form of the Child Behavior Checklist; VADPRS, Vanderbilt ADHD Diagnostic Parent Rating Scale; VADTRS, Vanderbilt ADHD Diagnostic Teacher Rating Scale; WPRS, Wender Parent Rating Scale; WURS, Wender Utah Rating Scale; YSR, Youth Self-Report. AAP 2000, American Academy of Pediatrics, Committee on Quality Improvement Subcommittee on Attention-Deficit/Hyperactivity Disorder (2000) Clinical Practice Guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder; AAP 2001, American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder (2001) Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder; NZ 2001, New Zealand Ministry of Health (2001) New Zealand Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder; DGPPN 2003, Ebert D, Krause J, Roth-Sackenheim C (2003) ADHS im Erwachsenenalter - Leitlinien auf der Basis eines Expertenkonsensus mit Unterstützung der DGPPN; ESCAP 2004, Taylor E, Döpfner M, Sergeant J, Asherson P, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Rothenberger A, Sonuga-Barke E, Steinhausen HC, Zuddas A (2004) European clinical guidelines for hyperkinetic disorder - first upgrade; ESCAP 2006, Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, Döpfner M, Faraone SV, Rothenberger A, Sargeant J, Steinhausen HC, Sonuga-Barke EJ, Taylor E (2006) Long-acting medications for the hyperkinetic disorders. A systematic review and European treatment guideline; BAP 2006, Nutt DJ, Fone K, Asherson P, Bramble D, Hill P, Matthews K, Morris KA, Santosh P, Sonuga-Barke E, Taylor E, Weiss M, Young S; British Association for Psychopharmacology (2006) Evidence-based guidelines for management of attention deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology; DGKJP 2007, Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie (2007) Hyperkinetische Störungen (F90). In Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie (eds), Leitlinien zur Diagnostik und Therapie von psychischen Störungen im Säuglings-, Kindes- und Jugendalter. 3. überarbeitete Auflage; AACAP 2002, Greenhill LL, Pliszka S, Dulcan MK, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S; American Academy of Child and Adolescent Psychiatry (2002) Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents and Adults: AACAP 2007, Pliszka S; American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder; NICE 2008, National Institute for Health and Clinical Excellence (2008) Attention deficit hyperactivity disorder - Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72; SIGN 2009, Scottish Intercollegiate Guidelines Network (2009) Management of attention deficit and hyperactivity disorders in children and young people - A national clinical guideline; CADDRA 2011, Canadian Attention Deficit Disorder Resource Alliance (2011) Canadian ADHD Practice Guidelines, Third Edition.

Table 2 also lists recommendations for the psychiatric interview, collateral informants, use of rating scales and questionnaires. The role of rating scales receives a different emphasis in different guidelines. Rating scales are described as auxiliary diagnostic tools, as cost-effective methods of obtaining collateral information and as systematic outcome measures to demonstrate treatment outcome. Broad-based rating scales are described as facilitating the process of differential diagnosis and identification of comorbidity; rating scales of quality of life, adaptive skills and functioning are noted to provide added depth to the assessment. Recommendations for a psychoeducational assessment and laboratory tests vary widely between guidelines. Neuropsychological evaluation was not considered important for the diagnosis of ADHD to be established.

Differential recommendations for pharmacological treatment are listed in Table 3. Stimulants constitute the first-line pharmacological option in all published guidelines (Figure 2). NICE (2008) recommends methylphenidate as the first-line treatment option for ADHD in adults. CADDRA (2011) is the only guideline that makes a recommendation for the recently licensed lisdexamphetamine. The noradrenaline reuptake inhibitor atomoxetine is a recognized treatment option in most of the guidelines. Other drugs, such as bupropion, clonidine, guanfacine and tricyclic antidepressants were recommended for patients who have failed other treatments or suffer significant comorbidity, albeit not as first-line options. Pemoline received negative recommendations from AAP, BAP and AACAP, based on evidence of cases of liver failure. Despite antipsychotics receiving three positive recommendations, both NICE and NZ advised against the use of antipsychotics like risperidone, which is recommended by the International Consensus Statement on Management of ADHD and Aggression (Kutcher et al., 2004), a document that was not included in our systematic review.

Table 3.

Recommendations for pharmocological treatment of ADHD

Association	AAP (2000, 2001)	NZ (2001)	DGPPN (2003)	ESCAP (2004, 2006)	BAP (2006)	AACAP (2002, 2007)	DGKJP (2007)	NICE (2008)	SIGN (2009)	CADDRA (2011)
MPH	1st	1st	1st	1st	1st	1st	1st	1st	1st	+
MPH MR	1st	+	0	+	1st	1st	1st	1st	1st	1st
Dexamphetamine	1st	1st	+	+	1st	1st	+	+, 1st in C&A	1st	1st
Mixed amphetamine salts	1st	0	+	+	0	1st	+	0	0	1st
Lisdexamphetamine	0	0	0	0	0	0	0	0	0	1st
Atomoxetine	0	0	+	+	1st	1st	1st	+, 1st in C&A	+	1st
Bupropion	Outside scope	0	+	0	+	+	+	+	+	+
Clonidine	Outside scope	0	0	+	+	+	+	+	+	0
Guanfacine	0	0	0	+	+	+	+	0	0	0
Modafinil	0	0	0	0	+	0	0	+	-	+
Pemoline	-	0	0	+	-	-	0	0	0	0
TCA	Outside scope	+	+	+	+	+	+	+	+	+
Pre-treatment safety measures	0	+	0	0	0	+	+	+	+	+
Explicit dose	+	+	0	+	0	+	+	+	For some agents only	+
Titration	Outside scope	+	0	+	0	+	+	+	+	+
Monitoring	+	+	+	+	+	+	+	+	+	+
Adverse effects	+	+	0	+	+	+	+	+	+	+
Contra-indications	+	0	0	+	0	+	+	+	0	+
Cost considerations	0	0	0	+	+	0	+	+	0	+
Drug holidays	0	0	0	Only if growth retardation	0	+	+	-, exceptions permitted	0	-, exceptions permitted

0, no recommendation found; +, explicit favourable recommendation; -, negative recommendation; 1st, first line option; MPH, methylphenidate; MPHMR, methylphenidate modified release; TCA, tricyclic antidepressant. AAP 2000, American Academy of Pediatrics, Committee on Quality Improvement Subcommittee on Attention-Deficit/Hyperactivity Disorder (2000) Clinical Practice Guideline: Diagnosis and evaluation of the child with attention-deficit/hyper activity disorder; AAP 2001, American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder (2001) Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder; NZ 2001, New Zealand Ministry of Health (2001) New Zealand Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder; DGPPN 2003, Ebert D, Krause J, Roth-Sackenheim C (2003) ADHS im Erwachsenenalter - Leitlinien auf der Basis eines Expertenkonsensus mit Unterstützung der DGPPN; ESCAP 2004, Taylor E, DDpfher M, Sergeant J, Asherson P, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Rothenberger A, Sonuga-Barke E, Steinhausen HC, Zuddas A (2004) European clinical guidelines for hyperkinetic disorder - first upgrade; ESCAP 2006, Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, D Dpfher M, Faraone SV, Rothenberger A, Sargeant J, Steinhausen HC, Sonuga-Barke EJ, Taylor E (2006) Long-acting medications fo the hyperkinetic disorders. A systematic review and European treatment guideline; BAP 2006, Nutt DJ, Fone K, Asherson P, Bramble D, Hill P, Matthews K, Morris KA, Santosh P, Sonuga-Barke E, Taylor E, Weiss M, Young S; British Association for Psychopharmacology (2006) Evidence-based guidelines for management of attention deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology; DGKJP 2007, Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie (2007) Hyperkinetische Störungen (F90). In Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie (eds), Leitlinien zur Diagnostik und Therapie von psychischen Störungen im Säuglings-, Kindes- und Jugendalter. 3. überarbeitete Auflage; AACAP 2002, Greenhill LL, Pliszka S, Dulcan MK, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S; American Academy of Child and Adolescent Psychiatry (2002) Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents and Adults; AACAP 2007, Pliszka S; American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder; NICE 2008, National Institute for Health and Clinical Excellence (2008) Attention deficit hyperactivity disorder - Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72; SIGN 2009, Scottish Intercollegiate Guidelines Network (2009) Management of attention deficit and hyperactivity disorders in children and young people - A national clinical guideline; CADDRA 2011, Canadian Attention Deficit Disorder Resource Alliance (2011) Canadian ADHD Practice Guidelines, Third Edition.

There is clear disagreement among guidelines regarding specific psychosocial interventions for treatment of ADHD (Table 4). However, the majority of guidelines agree on the need for particular forms of psychosocial intervention including psychoeducation, individual education programmes with appropriate adaptations as needed, parent training and support for caregivers. All guidelines recommend that optimal management of ADHD should always include some form of psychosocial intervention with or without medication.

Table 4.

Psychosocial treatment recommendations

Association	AAP (2000, 2001)	NZ (2001)	DGPPN (2003)	ESCAP (2004, 2006)	BAP (2006)	AACAP (2002, 2007)	DGKJP (2007)	NICE (2008)	SIGN (2009)	CADDRA (2011)
Individual interventions	0	0	+	+	0	0	+	+	0	+
Group interventions	0	+	+	+	0	0	+	+	0	0
Family-based interventions	0	0	0	+	0	0	+	+	+	+
School-based interventions	+	0	0	+	+	0	+	+	+	+
Occupational interventions	0	0	0	0	+	0	0	0	0	+
Behavioural parent training	+	0	0	+	0	0	+	+	+	+
Behavioural management	0	+	0	+	0	0	+	+	0	+
Psychoeduation	+	0	+	+	+	+	+	+	+	+
Family therapy	0	0	0	0	0	0	+	0	0	+
Social skills training	0	0	0	+	0	-	0	+	0	+
Cognitive therapy	-	0	0	0	0	0	+	0	0	0
CBT	-	0	0	+	0	-	+	+	0	+
Supportive therapy	0	0	0	+	+	0	0	0	0	+
Self-help	0	0	0	+	0	0	+	+	+	+
Counselling	0	0	0	0	0	0	0	0	0	+
Cognitive remediation	0	0	0	Academic skills	0	0	+	0	0	Academic skills
Carer support	+	+	0	+	0	0	0	0	+	+
Other therapies	Play therapy not recommended	Dietary interventions supervised by dietitian and at parents’ request. Optometric vision training, sensory integrative training, chiropractic manipulation, tinted lenses, megavitamins, herbal remedies and biofeedback not recommended (-)	0	Elimination and restriction diets not routinely recommended (-)	0	Dietary modification and EEG biofeedback not recommended (-)	Dietary modification, biofeedback	Elimination and restriction diets not recommended; fatty acid supplements not routinely recommended (-)	Avoidance of case-specific food additives (+); omega-3 and omega-6 fatty acid supplements, iron supplements, zinc supplements, antioxidants, Bach flower remedies, homeopathy, massage therapy and neurofeedback (all -)	Anger management; interpersonal therapy; expressive arts therapy; play therapy.
Multimodal interventions	+	0	+	+	0	+	+	+	+	+

0, no recommendation found; +, explicit favourable recommendation; -, negative recommendation; C&A- child and adolescent. CBT, cognitive behavioural therapy; EEG, electroencephalography AAP 2000 , American Academy of Pediatrics, Committee on Quality Improvement Subcommittee on Attention-Deficit/Hyperactivity Disorder (2000) Clinical Practice Guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder; AAP 2001 , American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit Hyperactivity Disorder (2001) Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit/hyperactivity di Zealand Guidelines for the Assessment and Treatment of Attention-Deficit/Hype ractivity Disorder; DGPPN 2003 , Ebert D, Krause J, Roth-SackenheimC (2003) ADHS im Erwachsenenalter Leitlinienaufder Basiseines Expertenkonsensusmit UnterstUtzunger DGPPN; ESCAP 2004 , Taylor E, Döpfne M, Sergeant J, Asherson P, BanaschewskiT, BuitelaarJ, CoghillD, Danckaert M, RothenbergerA, Sonuga-Barke E, Steinhausen HC, ZuddasA (2004) European clinical guidelines for hyperkinetic disorder -first upgrade; ESCAP 2006 , Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, D Upfne M, Faraone SV, Rothenberger A, Sargeant J, Steinhausen HC, Sonuga-Barke EJ Taylor E (2006) Long-acting medications for the hyper kinetic disorders. A systematic review and European treatment guideline; BAP 2006 , Nutt DJ, Fone K, Asherson P, Bramble D, Hill P Matthews K, Morris KA, Santosh P, Sonuga-Barke E, Taylor E, Weiss M, Young S; British Association for Psychopharmacology (2006) Evidence-based guidelines for management of attentio deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychop harmacology; DGK JP 2007 , Deutsche Gesellschaf für Kinder -und Jugend für Kinder- und Jugend-psychiatrie und Psychotherapie (2007) Hyperkinetiche Störungern (90) In Deutsche Gesellschaft für Kinder- und Jugenpsychiatrie und Psychotherapie (eds), Leitlinien zur Diagnostik und Therapie von psychischen Störungen im Säuglings-, Kinder- und Jugendalter. 3. überarbeitete Auflage; AACAP 2002 , Greenhill LL, Pliszka S, Dulcan MK, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S; American Academy of Child and Adolescent Psychiatry (2002) Practice Parameter for the Use of Stimulant Medications in the Treatment of Children Adolescents and Adults; AACAP 2007 , Pliszka S; American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivi Disorder; NICE 2008 , National Institute for Health and Clinical Excellence (2008) Attention deficit hyperactivity disorder - Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72; SIGN 2009 , Scottish Intercollegiate Guidelines Network (2009) Management of attention deficit and hyperactivity disorders in children and young people - A national clinical guideline; CADDRA 2011 , Canadian Attention Deficit Disorder Resource Alliance (2011) Canadian ADHD Practice Guidelines, Third Edition.

Methodological quality

In the analysis of methodological quality of the reviewed guidelines (Table 5), the NICE Clinical Guideline 72 (NICE, 2008) achieved the highest score, followed by the guideline published by SIGN (2009).

Table 5.

Rating of methodological quality (AGREE scores)

Guideline	AAP (2000)	AAP (2001)	NZ (2001)	AACAP (2002)	DGPPN (2003)	ESCAP (2004)	ESCAP (2006)	BAP (2006)	DGKJP (2007)	AACAP (2007)	NICE (2008)	SIGN (2009)	CADDRA (2011)
Scope and purpose (maximum score 12)	11	8	11	7	5	3	8	8	4	4	12	11	10
Stakeholder involvement (maximum score 16)	8	9	13	4	7	5	5	7	5	4	13	10	9
Rigour of development (maximum score 28)	20	22	19	15	11	14	21	17	9	16	27	23	19
Clarity and presentation (maximum score 16)	15	12	14	12	12	12	12	14	12	16	16	14	16
Applicability (maximum score 12)	3	5	3	3	3	5	5	5	4	3	11	12	6
Editorial independence (maximum score 8)	2	2	2	3	2	5	6	8	2	5	8	8	8
Total score (maximum score 92)	59 (64%)	58 (63%)	62 (67%)	44 (48%)	40 (43%)	44 (48%)	57 (62%)	59 (64%)	36 (39%)	48 (52%)	87 (95%)	78 (85%)	68 (74%)

AAP 2000, American Academy of Pediatrics, Committee on Quality Improvement Subcommittee on Attention-Deficit/Hyperactivity Disorder (2000) Clinical Practice Guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder; AAP 2001, American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder (2001) Clinical Practice Guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder; NZ 2001, New Zealand Ministry of Health (2001) New Zealand Guidelines for the Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder; DGPPN 2003, Ebert D, Krause J, Roth-Sackenheim C (2003) ADHS im Erwachsenenalter - Leitlinien auf der Basis eines Expertenkonsensus mit Unterstützung der DGPPN; ESCAP 2004 , Taylor E, Döpfner M, Sergeant J, Asherson P, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Rothenberger A, Sonuga-Barke E, Steinhausen HC, Zuddas A (2004) European clinical guidelines for hyperkinetic disorder - first upgrade; ESCAP 2006, Banaschewski T, Coghill D, Santosh P, Zuddas A, Asherson P, Buitelaar J, Danckaerts M, Döpfner M, Faraone SV, Rothenberger A, Sargeant J, Steinhausen HC, Sonuga-Barke EJ, Taylor E (2006) Long-acting medications for the hyperkinetic disorders. A systematic review and European treatment guideline; BAP 2006, Nutt DJ, Fone K, Asherson P, Bramble D, Hill P, Matthews K, Morris KA, Santosh P Sonuga-Barke E, Taylor E, Weiss M, Young S; British Association for Psychopharmacology (2006) Evidence-based guidelines for management of attention deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology; DGKJP 2007, Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie (2007) Hyperkinetische Störungen (F90). In Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie (eds), Leitlinien zur Diagnostik und Therapie von psychischen Störungen im Säuglings-, Kindes- und Jugendalter. 3. überarbeitete Auflage; AACAP 2002, Greenhill LL, Pliszka S, Dulcan MK, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S; American Academy of Child and Adolescent Psychiatry (2002) Practice Parameter for the Use of Stimulant Medications in the Treatment of Children, Adolescents and Adults; AACAP 2007 , Pliszka S; American Academy of Child and Adolescent Psychiatry (AACAP) Work Group on Quality Issues (2007) Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder; NICE 2008, National Institute for Health and Clinical Excellence (2008) Attention deficit hyperactivity disorder - Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72; SIGN 2009, Scottish Intercollegiate Guidelines Network (2009) Management of attention deficit and hyperactivity disorders in children and young people - A national clinical guideline; CADDRA 2011, Canadian Attention Deficit Disorder Resource Alliance (2011) Canadian ADHD Practice Guidelines, Third Edition.

All guidelines gave specific and unambiguous recommendations and presented different management options clearly. In general, they scored well ‘on clarity and presentation’. Patients’ views and preferences were only taken into consideration by two guidelines (NZ and NICE). None of the guidelines was piloted among target users. The documents produced by SIGN, CADDRA and NICE were revised in response to an external review process prior to publication. Only the NICE guideline provides a clear statement for the procedure and timeline for ongoing revision. The NICE guideline was also the only one to consider cost implications of its implementation in detail. Two guidelines from the United Kingdom (NICE and SIGN) provide criteria and/or materials for monitoring or audit purposes, derived from their key recommendations. Only five guidelines (ESCAP 2004, BAP, NICE, SIGN and CADDRA) provide satisfactory information on their editorial independence from the funding body.

Discussion

This is the most comprehensive review of guidelines on diagnosis and/or management of ADHD so far, looking at 13 guidelines from 10 medical associations. The systematic review highlights consensus and differences between recommended practices throughout the lifespan and in different geographical areas. The results can be used to inform the development of better and revised guidelines.

The clinical guidelines reviewed here reflect different healthcare systems and countries, as well as different aims and targeted professional groups from primary care to tertiary specialists. One limitation of this approach is the comparison of recommendations that do not necessarily share a common denominator. The reviewed guidelines were published over a period of eleven years and looked at the evidence available at the time, which can explain some of the chronological variability of the recommendations. It is possible that other guidelines exist or are about to be published, which were not identified by our search.

All guidelines agree that the diagnosis of ADHD is based on a full clinical interview, which includes a mental state examination, assessments of impairment, development, comorbidity and family history as well as a physical examination. All guidelines for children recommend a family interview. All guidelines agree that the clinical interview remains the ‘gold standard’ of assessment for ADHD, whereas the use of rating scales has standardized and improved the reliability, breadth and efficiency of assessments. The importance of the exclusion of physical and psychiatric comorbidity is also highlighted in all analysed guidelines.

When pharmacological treatment is indicated, the reviewed guidelines unanimously suggest the use of stimulants in children, adolescents and adults. Mixed amphetamine salts are notrecommended by three guidelines, two of them European, where this pharmacological option is not licensed. Nevertheless, three European guidelines make favourable recommendations for their use. The role of atomoxetine varies between guidelines, where it is perceived as a valuable treatment for patients with comorbid substance use, anxiety, tics, late evening worsening, growth deficits or insomnia. All other medications are clearly framed as second-line options.

The recommendations for psychosocial interventions are far from consensual. There are a number of possible reasons for this lack of agreement. First of all, there is less evidence to support any given psychological treatment as compared to medication, and the methodological standards for research into psychological treatments are less well established. Despite this relative weakness all guidelines agree on the need for psychological interventions of some kind based on both patient satisfaction and face validity. Two recent publications on effective individual (Safren et al., 2010) and group (Solanto et al., 2010) cognitive behavioural therapy for adults with ADHD are likely to influence the recommendations of future guidelines. Questions of service provision, management priorities, availability of therapy, and the ecological relevance of research results (e.g. findings from the MTA study (The MTA Cooperative Group, 1999)), are variable across different countries and healthcare systems. Again, this represents an important opportunity for future guideline development. For example, in one country psychological testing may be both available and considered essential to rule out learning disabilities, but may not be recommended in another country where it is not part of standard clinical practice. The continued development of practice guidelines for different age groups and societies adds further to the understanding that ADHD crosses national boundaries and that there is a potential not only for evidence based consensus guidelines within countries, but also for international or at least multinational guidelines.

The implementation of national and international guidelines at a local level of healthcare delivery poses particular challenges in view of the different organization of healthcare systems, economic constraints, tradition and local idiosyncrasies. It is unlikely that different healthcare systems are able to accommodate all the guidelines’ recommendations. They are likely to be of greater utility if used to inform local protocols adapted to the local reality. In this context, the observed guideline pluralism, with several guidelines on the same topic, some of them from different professional organizations within the same geographical area, is hardly justifiable in terms of health economics (Müller et al., 2003). Additionally, other documents such as influent expert consensus statements (Kooij et al., 2010; Remschmidt et al., 2005) further contribute to this pluralism. A more comprehensive approach, with international stakeholders and relevant organizations duly represented in the guideline development committee, could be adopted. At present, the impact of a guideline across continents is minimal and there is scope for international agreement on assessment, diagnosis and management of the same disorder.

The guidelines produced by NICE and by SIGN were found to have superior methodological quality, based on their AGREE scores. Notably, these guidelines were developed by associations specifically equipped for the production of guidelines, as part of a national healthcare policy. Other associations lacking this background focus on the evidence and consensus, rather than the actual process of guideline development, evaluation for bias, and rating of the quality of various recommendations. These guidelines written by experts for practitioners rather than by government agencies for standards of care received higher scores for the ‘clarity and presentation’ domain of the AGREE instrument. Guidelines that declared their funding arrangements in detail scored higher on the ‘editorial independence’ domain. Nevertheless, despite AGREE being a validated tool for the appraisal of methodological quality of a guideline, it is unclear what the concept of methodological quality truly means. In other words, it is not certain that a lower score would necessarily mean less valid recommendations. The generally poor scores on the ‘applicability’ domain raise questions of how the recommendations can be implemented. Although some studies demonstrate that guideline adherence by clinicians can be improved by training based on guideline recommendations (Pliszka et al., 2003; Wolraich et al., 2010), further research on guideline implementation and resource implications is needed.

Footnotes

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

UM has received research grant support from Janssen-Cilag and honoraria or travel expenses from Bristol-Myers Squibb, Eli Lilly, Janssen-Cilag, Pharmacia-Upjohn, and UCB Pharma. MW has consulting, speaking, honoraria, and research funding from Eli Lilly, Shire, Janssen-Cilag, and Purdue, as well as a consulting agreement with Takeda. MW was involved in the development of the BAP and CADDRA guidelines.

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