ADHD in Children & Adolescents –
A Good Practice Guidance
This guideline has been developed on behalf of the Executive Committee of the George Still
Forum, the National Paediatric ADHD Network Group in the UK. It can be used by
paediatricians, child & adolescent psychiatrists, clinical psychologists, nurses and other
healthcare professionals working in the field of ADHD in the UK.
Issue Date: 5 April 2011
Review Date: 4 April 2013
www.georgestillforum.co.uk
1
Contents
1. Introduction
3
2. Objectives of GSF
3
3. Incidence
4
4. Symptoms
4
5. Assessment and monitoring
4
6. Management
6
7. Other management options
12
8. Adolescents
12
9. Comorbidities
13
10. Cardiac risks of ADHD medications
15
11. Interventions
16
12. Treatment options
16
13. Management of some common problems
17
14. References
20
15. Appendix 1 Side effect questionnaire
22
16. Appendix 2 Care pathway
23
17. Appendix 3 Shared Care
24
18. GSF Executive Committee
26
2
1.
INTRODUCTION
George Still Forum is an apex organisation of the paediatricians, involved in assessment and
monitoring of ADHD in children and adolescents. The group is recognised by the Royal College
of Paediatrics and Child Health as a special interest group. The aims of the forum are to
exchange ideas, to increase professional awareness, to liaise with other professional groups, to
influence public policy decisions where appropriate, to share information in relation to current
issues in providing services to individuals and their families and to improve care for children and
adolescents with ADHD.
There is an increase in number of ADHD patients countrywide, highlighting the shortfall in
resources and extended waiting times for the new assessments. This situation is posing an
extra burden and is a threat to burn out amongst ADHD clinicians. George Still Forum aims to
bring these issues to the notice of the commissioners in the National Health Service.
2.





OBJECTIVES OF THE GSF
To take a leadership role in managing ADHD in children and adolescents.
To develop the ADHD guidelines for the Paediatricians in the UK.
To facilitate development of training standards.
To share information with the stakeholders.
To advocate to NHS commissioners about ADHD.
3
3.
INCIDENCE
Estimates of the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) indicate that
around 3 to 9% of school-aged children and adolescents would meet the Diagnostic and
Statistical Manuel-IV (DSM-IV) of American Psychiatric Association’s diagnostic criteria for
ADHD1. Follow-up studies of children with ADHD find that 15% still have the full diagnosis at 25
years, and a further 50% are in partial remission, with some symptoms associated with clinical
and psychosocial impairments persisting2.
4.
SYMPTOMS
The three core symptom domains of ADHD are inattention, hyperactivity and impulsivity.
Subtypes of ADHD are diagnosed based on meeting the symptom thresholds according to the
Diagnostic and Statistical Manual of American Psychiatric Association3. The International
Classification of Diseases of World Health Organization described this condition as hyperkinetic
disorder4. The symptoms and subtypes of ADHD and associated comorbid disorders change
through out the lifecycle. Hyperactivity and impulsivity may decrease as patients get older but
the demands on their attention may increase. The Predominantly Inattentive Subtype may be
more obvious by adulthood.
5.
ASSESSMENT AND MONITORING
ADHD is a chronic medical condition and needs a long term management plan5. ADHD patients
deserve every opportunity to attain their full potential by having timely assessments to identify
their impairments and to access the best management. Like other medical conditions in Child
Psychiatry, ADHD is a clinical diagnosis for which there are no specific signs. It is diagnosed
when parents/carers and school report overactivity, impulsivity and/or short attention span. It is
therefore important to gather the information from parents/carers and school before arriving at
the diagnosis. The observation of the child in a clinic setting is unlikely to rule out the diagnosis.
ADHD can be provisionally diagnosed in preschool children but it should be confirmed after the
child has started school. The initial assessment for ADHD should include:
5.1
Presenting Complaint
A. Review with the parents of their concerns, the reason for referral, and the parents’
expectations from the assessment. Most often, a parent will come to discuss about
hyperactivity, impulse control, inattentiveness or educational concerns. Parents should be
asked about the pervasiveness of the symptoms.
B. Review with the child/adolescent and parents/carers the completed rating scales.
C. Interview with the child and parents/carers.
D. Medical history and physical examination to ensure that there are no other medical causes
for the symptoms of ADHD and to ensure that there are no medical contraindications to the
possible use of medications.
5.2
Medical Assessment
Medical assessment should include a perinatal and developmental history and a physical
examination including neurological examination and for any contraindications for medication
use, such as some cardiac dysrhythmias. Any abnormalities that are found in the physical
examination should be followed by more detailed and specific tests. A history of sleep pattern as
well as any preference to a fixed routine in daily life should be obtained. Vital signs of height,
weight, blood pressure, and pulse rate should be documented and plotted on centile charts as
baseline and during each follow-up visits if medication is prescribed. The following points should
be included in the history during the initial assessment:
4
5.2.1 Antenatal History:
o Antenatal infections (e.g., TORCH).
o Smoking cigarettes, cannabis etc (how many a day, How often and how long?)
o Exposure to drugs
o Exposure to alcohol
o High-risk pregnancy (e. g. premature delivery, LBW).
o History of birth asphyxia.
5.2.2 Behavioural / Developmental History:
o Early developmental milestones.
o High activity level and difficulty engaging in quiet play.
o Problems with obeying commands and oppositional behaviour.
5.2.3 Family History:
o Parent or sibling with school failure.
o Parent and/or sibling history of ADHD.
o Drug or alcohol abuse.
o Psychiatric illnesses.
o Problems with the law.
o Cardiac arrhythmias or sudden death especially in 35 years or younger age.
5.2.4 Home Environment:
o Key caregivers.
o Frequent moves?
o Frequent changes in school?
o Chaotic home environment?
o Poor or crowded housing?
o Excess (>2 hours/day) TV, computer, video games?
5.2.5 Peer Relationships:
o Plays alone as has no friends.
o Problems in maintaining friendships.
5.2.6 School History:
o Academic under-achievement.
o Truancy.
o Does the child enjoy school?
o Ask the school age child if he/she thinks he/she has trouble concentrating.
o Review current school report as well as those from earlier years.
o Specific Learning Difficulty (SLD; Dyslexia) is part of the differential and/or is
comorbid with ADHD. Educational evaluation contributes to identification of SLD,
learning strengths, under achievement relative to potential, impact of ADHD on
learning and identification of processing speed, working memory and peer
relationship skills.
5.2.7 Eating History:
o Appetite.
o Any dietary restrictions.
o Skipping meals regularly.
o Joins family members for dinner?
5
5.2.8 Physical examination
It is important to document a baseline physical examination. Special attention should be
paid to the following elements of the exam:
o Growth parameters. Height and weight will need to be plotted on a centile chart
as baseline and at each follow-up visit if the child is prescribed medication.
o Blood pressure and pulse rate are recorded and plotted on the centile chart.
o Cardiac examination including auscultation for murmurs and femoral pulses.
o Dysmorphic features suggestive of Fetal Alcohol Syndrome (FAS) or other
genetic conditions.
o Thyroid enlargement.
o Cutaneous stigmata, such as café au lait spots.
o Bruising or other evidence of injury (accidental or intentional).
o Tonsillar hypertrophy, mouth breathing etc which may contribute to sleep apnea.
o Neurologic exam and age-appropriate mental status exam.
o Tics, either motor or vocal or both.
o General behaviour: overall activity level, restlessness.
o Observe the child/parent interaction.
o Vision & Hearing screen (if indicated).
5.3
Cognitive Assessment
The child should have a cognitive assessment in school preferably by an Education
Psychologist for possibility of associated SLD. Academic achievements in key subjects are
important as they may suggest the need for additional educational needs.
5.4
Emotional/Behavioural Assessment
Assessment for any possible comorbid condition in the child is important. Input from the child’s
teachers regarding his/her social, academic and emotional functioning is valuable as teacher/s
can compare the child in the classroom setting compared to other pupils of same age range.
5.5
Feedback and Expectations
Ensure that the patient and family have had an adequate opportunity to know about ADHD and
various treatment options. They should be provided written information about ADHD and
available option of various management strategies, website addresses, and contact details of
the local support groups. Do ask the family to find out more about ADHD. Instruct the family to
do some research on ADHD. Only proceed to feedback and treatment if the child has well
documented evidence of impairment and meets the thresholds for ADHD, shows no other
medical problems that would contraindicate further treatment and has parent(s)/carer(s) who are
motivated. They need to know the symptoms that are being treated (no medication effectively
eliminates all the symptoms of ADHD). There must be a discussion of the risks and benefits of
the prescribed treatment and the alternatives. There needs to be discussion regarding potential
risks of no treatment. Describe the key findings obtained from the assessment. Include a clear
statement about the diagnosis and the basis on which the diagnosis is made. Explain to the
family that you will be sending them a report and a copy made for the school, GP and other
relevant agencies involved.
6.
MANAGEMENT
ADHD is a clinical diagnosis based on a combination of a reliable history, reports from home
and school and a physical examination to rule out any other underlying medical conditions.
Therefore it is important that symptoms be recorded using valid, reliable and sensitive rating
scales to evaluate symptom frequency and severity. Rating scales are not diagnostic; they give
information about a child’s current functioning and difficulties. Rating scales can also be used to
monitor treatment efficacy and side effects.
6
6.1
Drugs
Medications are to facilitate a holistic approach and are not a stand alone intervention. Discuss
the drug treatment options. There is no one drug that is suitable for every patient. The guiding
principle of drug intervention is to start in a low dosage and gradually increase it, though weightbased dosage may be used as a way of gauging adequate dosing. Parents should be informed
that well controlled studies have shown medication to be safe and very effective in treating the
symptoms of ADHD. In ADHD with comorbidity, multiple medications may be used. Start
medication in low dosage and go slow but continue increasing the dose until maximum
recommended dose level is reached or to where the target symptoms show improvement or the
side effects appear. At the end of the visit, give the parent(s)/carer(s) the rating scale to be
completed by parent(s)/carer(s), the rating scale to be completed by the class teacher and the
side effect form that should be filled out by the parent(s)/carer(s) before medication is started
and then every week.
After establishing the diagnosis of ADHD with comorbidities if medication is considered then try
stimulant if immediate response needed. If there is evidence of tics then non-stimulant is
recommended. Similarly if there is need for late evening and early morning cover then nonstimulant medication may be tried.
6.3 Choice of medication
The choice of medication will depend on the following factors:
1. Age
2. Duration of effect
3. The onset of action of the medication
4. Comorbid disorders
5. History of earlier medication use
6. Attitudes towards medication use
7. Presence of comorbid tics, anxiety
8. Other associated medical problems
9. Associated features similar to medication side effects
10. Combining stimulants with other medications
11. Drug diversion
12. Clinicians’ attitude towards ADHD medications
1. Age dexamfetamine (DEX) is licensed from 3 years of age and methylphenidate (MPH) and
atomoxetine (Strattera) from 6 years of age. There is no maximum age to treat ADHD. A
caution is needed to use drugs in women of childbearing age as effects of ADHD
medications on the foetus and on breast-feeding are unknown.
2. Duration of effect Tasks that require mental effort change over the years. In childhood
there may only be a need to treat during daytime while in adolescents, the need to cover the
evenings may be necessary. This may be critical for tasks such as driving.
3. The onset of action of the medication When patients require rapid response, stimulants
are the treatments of choice. Non stimulant may require two to six weeks to show a
treatment response.
4. Comorbid disorders When there is a comorbid disorder along with ADHD, it is generally
advised that the ADHD should be treated first. However, major mood disorders like
Depression, Bipolar Disorder, and Substance Abuse Disorder should be identified and
treated prior to ADHD. If the relevant comorbidity puts the patient at risk for harm to others
or to himself/herself, then this comorbidity takes precedence for treatment. It is important to
review drug to drug interactions to ensure that there is no risk to the patient.
7
5. History of earlier medication use If there is a lack of improvement or substantial side
effects, another ADHD drug may be considered. If a patient is responding well to one
medication, it is advised that another medication should not be tried to see if there is a better
response. Patients who do not respond to one stimulant may very well respond to another
(e.g., MPH vs. DEX). The same seems to be true for side effects; one may be better
tolerated than the other.
6. Attitudes towards medication use Patients and their families/carers need to be educated
about ADHD and current management. The choice of medication should follow the informed
consent. Biases against the use of ADHD medications are often due to misinformation
regarding side effects and guilt about having caused the problem due to bad parenting.
Alternatively, parents/carers may have excessive expectation from drug therapy and may
lead to disappointment. Drugs are part of the holistic approach.
7. Presence of comorbid tics, anxiety Stimulants and non-stimulant may be used in
presence of comorbid tics or anxiety.
8. Other associated medical problems It is important for the clinician to do a thorough
medical assessment including physical examination before prescribing medications. Many
conditions look like ADHD (e.g., hyperthyroidism, hearing deficits, Autism Spectrum
Disorder, Learning disability or Specific Learning Difficulty etc). It is important for clinicians to
be aware of any other medical condition the patient may have that affects suitability for a
medication.
9. Side effects All drugs have side effects. Most side effects usually improve over one to two
weeks of continuous use. One of the most common reasons for non-compliance is related to
a lack of awareness or understanding of the side effects. Patients’ understanding of the side
effect profile of each medication may afford a better compliance.
10. Polypharmacy When a clinician feels that a second medication is needed, it is advised to
begin with an ADHD medication that is known to combine safely with the second
medication. For example, in the selection of an ADHD medication for a patient with severe
conduct disorder and aggressive behaviour, a psychostimulant could be combined with an
atypical antipsychotic6. Some of the side effects related to drug interaction occur because of
competition for liver enzymes that metabolise the drug.
11. Drug diversion Patients or parents/carers, who are at risk for substance abuse/drugdiversion should not be prescribed short-acting stimulants.
12. Clinicians’ attitude towards ADHD medications Information on ADHD is rapidly evolving
(i.e., understanding of comorbidity, adult ADHD, drugs, etc). It is imperative that clinicians
have updated information to practice evidence based medicine.
6.4






Follow-up visits
Monitor response by using rating scales.
Monitor side-effects.
Monitor the medication dosage.
Parent and teacher rating scales should be obtained for each follow up visit.
A telephone call may be beneficial to follow up the prescribed ADHD medication till the
dose is optimised.
Once a stable optimal dose has been determined, the ideal medication follow-up is 6
months. Non-compliance to treatment may be related to lack of frequency of follow-up.
8
6.5





Monitoring
A baseline rating of clinical symptoms is needed before considering medical treatment.
The patient may not be the best informant regarding efficacy as they often have poor
self-awareness. Helping the adolescent to understand this is a key point in
psychoeducation.
School performance is a useful indicator of treatment effect.
Get information from one teacher the adolescent likes and one they dislike so as to get
the best range of teacher observation.
Side-effects may be assessed by the parent/carer through the use of a structured
questionnaire (appendix I).
6.6
Side-effects
If a change of medication is thought necessary because of side-effects, switch medication
during school holidays to avoid possible side effects that may impair school performance. If a
‘trial off’ medication is required, it should preferably be done during school holidays to minimize
impact on school performance.
6.7 Available drugs in UK
ADHD drugs are indicated as part of a comprehensive treatment programme for ADHD.
Treatment must be initiated by child and adolescent psychiatrists, paediatricians with expertise
in ADHD, ADHD Specialist Nurse Prescribers or GPs with a special interest (GPSi) in ADHD.
Methylphenidate and Atomoxetine are not licensed for use in children less than six years of age
or in adults. Dexamfetamine may be prescribed after 3 years of age. Stimulants are not licensed
for children with marked anxiety, agitation or tension, symptoms or family history of tics or
Tourette’s syndrome, hyperthyroidism, angina or cardiac arrhythmia, glaucoma or
thyrotoxicosis. Stimulants are controlled by the Misuse of Drugs Act 1971 (Schedule 2 drug)
and are subject to the regulations for Controlled Drugs. For details the practitioners are advised
to consult the European treatment guideline12, 15.
6.7.1 Presentations:
Methylphenidate immediate release (IR) is available as 5, 10 and 20mg tablets (5 and 20mg
only available as Medikinet and methylphenidate tablets).
Medikinet® XL (methylphenidate) is available as 10, 20, 30, and 40mg sustained release
capsules.
Equasym® XL (methylphenidate) is available as 10, 20 and 30 mg sustained release capsules.
Concerta® XL (methylphenidate) is available as 18, 27 and 36 mg sustained release tablets.
Dexedrine® (Dexamfetamine) is available as: 5 mg tablets.
Atomoxetine (Strattera®) is available as 10, 18, 25, 40, 60 and 80mg capsules.
Methylphenidate and dexamfetamine are Schedule 2 Controlled Drugs and therefore
prescriptions must be written according to legal requirements.
6.7.2 Recommended dosage and administration
Methylphenidate IR
Methylphenidate is a central nervous system stimulant. Initial dose can begin at 5mg once or
twice daily (2.5mg for a younger child), and increase if necessary by weekly increments of 510mg in the daily dose. If improvement of symptoms is not observed after appropriate dosage
adjustment over a one month period, the drug should be discontinued. The maximum
recommended dosage for methylphenidate is 0.7mg per dose or 2.1mg daily in divided doses. It
is licensed from six years to 17 years of age. Methylphenidate is active for about four hours after
the last dose taken. Unwanted effects of appetite suppression can be avoided by advising after
9
breakfast and lunch. Methylphenidate has an effective life of between three and a half and four
hours, so the dose regime must be based on this period. Unwanted normal effects of appetite
suppression and sleep inhibition are usually accommodated by prescribing to cover the 8am to
6pm period and using it for school days only in most cases. Methylphenidate is active for about
four hours after the last dose taken. The inadvertent omission of a dose simply allows the
child’s behaviour to revert to the untreated state until the next dose is taken.
Methylphenidate sustained release
To ensure optimal length of activity to cover the school day, a sustained release preparation
may be considered. Table 1 describes the various sustained release preparations available in
UK.
Long acting stimulants
®
Concerta XL
Duration of Action
Dosage / Day
12 hours
Max licensed
54 mg per day
8 hours
10 – 60 mg.
18mg, 27mg or 36mg
tablets
®
Equasym XL
10mg, 20mg, or 30mg
capsules
®
Medikinet XL
10mg, 20mg, 30mg &
40mg capsules
Max. licensed
dose 60 mg
per day.
8 hours
10 – 60 mg.
Max. licensed
dose 60 mg
per day.
Comments
 Has 22% IR* & 78% SR#
 Swallow whole
 Tablet ‘shell’ may appear
in the faeces
 Has 30% IR* & 70% SR#
 Swallow whole or empty
capsule contents onto
one spoonful of apple
sauce or similar soft food
such as yoghurt
 Has 50% IR* & 50% SR#
 Swallow whole or empty
capsule contents onto
one spoonful of apple
sauce or similar soft food
such as yoghurt
* IR= Immediate release; # SR= Sustained release
Equasym XL is a registered trademark of Shire, Concerta XL is a registered trademark of Janssen-Cilag Ltd, Medikinet XL
is a registered trademark of Medice GmbH.
Dexamfetamine
Dexamfetamine is also a central nervous system stimulant. Its effects and adverse event profile
are similar to methylphenidate, but there is much less evidence on efficacy and safety that
exists for methylphenidate and it plays a part in illegal drug taking. The initial dose may be
2.5mg once or twice daily and increase if necessary by weekly increments of 5-10mg in the
daily dose. The maximum licensed dose is 60mg daily in divided dosage. It can be used from 3
years to 17 years of age. The tablets can be halved.
Atomoxetine
Atomoxetine is a suitable first line alternative and is a non stimulant drug. It may be particularly
useful for children who do not respond to stimulants. Certain situations such as co-morbidity
with tics, Tourette’s syndrome, epilepsy or substance abuse would support atomoxetine as a
first line option. Limited information is available comparing Atomoxetine to stimulants in relation
to efficacy. It is available as Strattera® 10, 18, 25, 40 & 80 mg capsules. It is a registered
trademark of Eli Lilly. The dose is usually administered as a single daily dose but can also be
given twice a day. The starting dose in six years or older and adolescents with body weight up
10
to 70kg is 0.5 mg/kg/day for 7 days. Usual maintenance dose is 1.2 mg/kg/day. In a child and
adolescent with body weight at 70kg or more the initial recommended dose is 40mg daily for
seven days. The maximum licensed dose is 1.8 mg per kg per day or 120mg per day. The
plasma half-life is 3.6 hours in extensive metabolizers and 21 hours in poor metabolizers.
Patients on atomoxetine should be monitored for signs of liver functions, depression, suicidal
thoughts or behaviour and referred for appropriate treatment if necessary.
6.8
Adverse effects of drugs
The most common side-effects reported with methylphenidate treatment are insomnia,
decreased appetite, pain in abdomen and headache. They are often mild and transient, and
may be alleviated by reducing the dosage. Adjusting dosage times may help to alleviate
insomnia. Unwanted effects of appetite suppression can be avoided by advising that the tablets
are taken after breakfast and lunch. A very rare but important adverse reaction is bone marrow
suppression. A routine full blood count is not warranted unless there is a clinical indication.
Abdominal pain and decreased appetite are the most commonly reported adverse effects with
Atomoxetine. In the initial period nausea and vomiting can occur in some children. Although
rare, suicide-related behaviour (suicide attempts and suicidal ideation) have also been reported
in patients treated with Atomoxetine.
Hostility (predominantly aggression, oppositional behaviour and anger) is an uncommon
adverse effect, occurring in between 0.1 – 1% of patients; treated with atomoxetine. A full list of
potential adverse effects is listed in the BNF for children and summary of product characteristics
(SPC) of individual drugs. They are also available online on the Electronic Medicines
Compendium website (http://www.medicines.org.uk/emc/). Side effects which may warrant dose
omission until discussed with an ADHD specialist include raised blood pressure, increase in
seizure frequency in patients with epilepsy, heart rhythm changes, blurred eyesight, evidence of
rare blood disorders.
Practice point:
Methylphenidate/ dexamfetamine/atomoxetine dependence is not a
problem in the drug therapy of ADHD.
6.9
Precautions and Contra-indications
A full list of precautions / contra-indications are included in the BNF and Summary of product
characteristics. Atomoxetine should be discontinued in patients with jaundice or laboratory
evidence of liver injury. Very rarely, liver toxicity with elevated hepatic enzymes and bilirubin has
been reported.
6.10 Drug Interactions
Methylphenidate increases plasma concentrations of phenytoin and delays intestinal absorption
of phenytoin, phenobarbitone and ethosuximide. Methylphenidate inhibits metabolism of tricyclic
antidepressants and warfarin. Methylphenidate should be used with caution in patients receiving
MAOI’s as there is a risk of hypertensive crisis.
Atomoxetine can be combined with stimulants to augment the effect in the case that the clinician
feels the patient has not achieved an adequate response4. Such a combination should be
initiated by a secondary care provider with specialization in ADHD. The combinations are used
sometimes in clinical practice although it is not recommended nationally. Results from the
handful of studies suggest that combining stimulant therapy with nonstimulant alternatives may
result in more significant symptom reductions in patients for whom monotherapy is less than
optimal. There are no studies to suggest that combing stimulant with a non-stimulant increases
the risk of cardiac side-effects. The best practice will be to exclude any family history and a
cardiac evaluation before start of a drug trial.
11
Full lists of drug interactions are included in the SPC.
6.11 Drug holiday
Recent evidence suggests that minor height changes (up to 2 cm) may occur on stimulants 9
although it is unclear whether ADHD children tend to be smaller. If there is concern then families
should be given the option of whether to have drug holidays or to lower the dosage on
weekends and during school holidays. Non-stimulant medications must be given continuously
as they rely on a blood level being sustained for treatment efficacy. Maintaining some
medications continuously has the additional advantages of allowing side effects to settle and
enabling the child to behave more consistently, thereby improving their self-esteem and social
skill abilities.
7
OTHER MANAGEMENT OPTIONS
7.1
Behavioural interventions
ADHD patients may take longer time to integrate socially acceptable habits into their lives. The
key factor is to create a positive environment that motivates the individual.
7.2
Psychological treatment
ADHD patients are at significant risk of being involved with bullying as a bully, as a victim or
both. There is a direct effect on their self-esteem. They require a positive environment and
sensitivity and understanding. Interventions may include individual and/or family support,
counseling, and therapy.
7.3
Educational modifications
A child with ADHD should have access to additional educational needs where necessary.
8.
ADOLESCENTS
Adolescents may present differently than younger children. They are less likely to be as
overactive, although they may be fidgety and can be restless. Low self-esteem may result from
school underachievement.
8.1
Medical Evaluation
In addition to the history and physical examination mentioned in 5.2, medical evaluation of the
adolescent should include eliciting history regarding:
 Eating habits
 Menstrual/pubertal status.
 Use of alcohol and drugs.
 Cigarette smoking.
 Driving.
8.2




8.3



Psychosocial Evaluation
Specific precipitant where symptoms can be dated.
Events precipitating ADHD symptoms such as neglect, physical or sexual abuse.
Parenting issues and
Home environment.
School Evaluation
Completed rating scales from school. Adolescents often can give guidance about which
teachers know them best.
School report.
Psychometric evaluation by education psychologists for cognitive abilities, academic
achievement levels, and learning disabilities.
12
8.4




8.5




Social History
History of substance use.
Number of accidents and speeding tickets.
Sexual activity and use of contraceptive methods.
Spending history (gambling, shopping).
Compliance
Between a third and a half of medicines that are prescribed for long-term conditions are
not used as recommended7. As many as 48-68% of adolescents stop their ADHD
medications. 8
Psychoeducation is the most useful means of ensuring compliance.
The primary aim should be to get the adolescent to take responsibility for his/her own
medications. Parents/guardians involvement may be necessary to ensure that
medication is taken as scheduled. However, a power battle will inevitably result in poor
compliance and it may be more important to just involve the adolescent alone.
Once-daily dosing improves compliance.
8.6
Safety Issues
It is good practice to explain to a teenager about the condition and the option of various drugs to
gain her/his confidence. Combining medications for ADHD with illicit drugs or alcohol could be
dangerous as the effects may be exaggerated. The use of medications may protect them from
poor social skills so it is helpful if they do not skip the dosage on weekends and during school
holidays.
8.7



Pharmacokinetics
Puberty is a time of significant physical change and the adolescent patient may be
develop side effects in small doses. It is recommended that the first dose should be low
but with gradual increase.
The concurrent use of illicit substances is likely to increase the blood levels of most
drugs metabolised in liver.
There is no established dose-response curve for adolescents.
9.
Guidelines
There are many guidelines including the American Academy of Child and Adolescent Psychiatry
Guidelines10, the American Academy of Pediatrics Guidelines11, the European Treatment
Guidelines12, National Institute for Health and Clinical Excellence13 and the Scottish
Intercollegiate Guideline Network14.
10.
COMORBIDITIES
10.1 Oppositional Defiant Disorder (ODD)
In childhood, the most common comorbid disorders are ODD in as many as 40% of ADHD
children15. ODD is characterized by the child’s inability to accept parental authority and the
strong need to be in control. Distinguishing between normal adolescent self-assertion and ODD
may not always be easy. Treatment of the ADHD may not resolve all ODD symptomatology,
which may require additional individual and family interventions. Behavioural interventions are
important. Strategies leading to positive reinforcement and targeting positive goals are often
useful. Use of time-out and appropriate strategies that are applied with consistency also help to
deal with the oppositional defiance. Behavioural interventions are effective, but they need to be
consistent and ongoing.
10.2 Conduct Disorder (CD)
The risk for the development of CD in children with both ADHD and ODD is two to three times
greater than in children with ADHD without ODD16. Behavioural intervention strategies are
13
necessary for this disorder. Comorbid CD also puts children at risk for gravitating towards other
children with similar problems. Strategies that promote positive peer relationships and effective
empathy development are indicated. A medication trial may be advised in conjunction with
comprehensive psychosocial treatment.
10.3 Learning Disability (LD)
Children with ADHD frequently fall below control groups on standardised achievement tests.
Children with ADHD often have weaknesses in the cognitive areas of executive functioning,
working memory and processing speed. When psychoeducational assessments are done,
emphasis should be placed on assessing these weaknesses as well as written output and
auditory processing. If LDs are documented, it may attract more one to one support and ageappropriate educational progress.
10.4 Aggression
Verbal and physical aggression is not uncommon in ADHD. The most common reason why
children with ADHD would act aggressively is a combination of ADHD with either ODD or CD.
Treating the ADHD is usually the first step. However, aggression might be part of another
diagnosis. Behavioural interventions and all ADHD medications may decrease aggressive
behaviour. If needed, new generation antipsychotic medications can be tried. A study has
shown that risperidone is effective in controlling ADHD, ODD and CD17.
10.5 Bipolar Disorder (BD)
This is an uncommon disorder in childhood. BD should be considered as the primary diagnosis
if there are prominent, episodic, cycling mood symptoms. BD may be suggested by: a) a strong
family history of BD or depression, b) paradoxical response to stimulants (worsening of mood or
rage symptoms).If BD is suspected, referral to a Child and Adolescent Psychiatrist is
recommended.
10.6 Pervasive Developmental Disorder (PDD)
PDD presents with difficulties in social communication, social interaction and stereotyped,
repetitive behaviour. Clinical symptoms of PDD supersede that of ADHD and should be the
primary diagnosis and can co-exist. The FDA recently approved the use of risperidone in
controlling aggressive and self-injurious behaviour and irritability18.
10.7 Depression
Many patients with Major Depression may present with transitional inattention, short-term
memory problems, irritability and impulsivity related to the mood disorders. When the
depression is associated with problems in the social environment, treatment strategies including
individual and family therapy are primarily indicated. Poor concentration may be part of a clinical
depression. A diagnosis of depression involves both a) depressed mood of more than two
weeks in duration more days than not and b) anhedonia. The stimulant medications may
produce a dysphoric look in 30% of patients even though the patient is not clinically depressed.
Adjustment of dose or switching to a different ADHD drug may improve the dysphoric
symptoms. Treatment of the most disabling condition should be undertaken first. This is
particularly true in the presence of suicide risk. Stimulants may produce a mild antidepressant
effect in some patients, while they may worsen mood in others. All of the drugs used to treat
ADHD have the potential to unmask a mood disorder or to cause mood symptoms.
10.8 Anxiety
Anxiety in ADHD can be manifested as Generalized Anxiety Disorder, Social Phobia,
Separation Anxiety Disorder, Post Traumatic Stress Disorder (PTSD) or Obsessive-Compulsive
Disorder (OCD). PTSD may be a misdiagnosed as ADHD as there are similar symptom
complex. PTSD is likely if there is no clear family history of ADHD or pre-morbid symptoms of
ADHD prior to the traumatic situation. If OCD exists then the combination with ADHD may be
14
part of a Tic Disorder (e.g., Tourette’s syndrome) so it is important to look for motor and phonic
tics.
10.9 Tic Disorders
Atomoxetine is a non-stimulant medication which does not aggravate tics. Stimulant
medications can be used to treat ADHD with tic disorders, but caution should be exercised as
tics may be exacerbated in some children.
10.10 Epilepsy
Children/adolescents with ADHD and comorbid epilepsy are at increased risk of seizures. There
is no available evidence that ADHD drugs decrease the seizure threshold. Therefore GSF is of
the opinion that ADHD drug may be used in such a situation.
10.11 Substance Use/Abuse Disorder (SUD)
ADHD patients are at increased risk of using illicit substances. It is important to point out that
the use of illicit substances does not have a positive therapeutic benefit. It is essential that a
history for substance abuse is explored with the individual alone. Ask whether their friends use
drugs or alcohol. A positive response suggests they are likely to be at high risk for substance
use.
11.
CARDIAC RISKS OF ADHD MEDICATIONS:
Sudden death in the ADHD population occurs in similar proportion to the general population.
Associated conditions in patients with sudden death on ADHD medications are very similar to
those with sudden death in the general population (structural heart disease, history of syncope,
family history of sudden death, exercise induced sudden death), and some of these clues can
help to suspect a higher risk, whether in the untreated or treated population. ECG abnormalities
can identify some individuals in the general population at risk for sudden death. Cost-Benefit
ratio in the school-age children is not clear and the usefulness of ECG screening in patients
being treated with or considered for ADHD drugs is unknown. The small but unproven potential
contribution of ADHD drugs to the rare incidence of sudden death in children and adolescents
must be weighed against the clinical benefit of the medication. Risk/benefit should be discussed
with the parent/patient as appropriate. In patients with cardiac conditions that place them at
increased risk for sudden death, ADHD medications should be contemplated only after
paediatric cardiology consultation and a thorough discussion of the risks and potential benefits
with the patient, family and consultants. In a child or adolescent with ADHD, who has no cardiac
symptoms, the risk of cardiac adverse events from ADHD medications is very low. The
American Heart Association Recommends19:
1. Before therapy with psychotherapeutic agents is initiated, a careful history should be
obtained with special attention to fainting or dizziness particularly with exercise, complaint of
chest pain or shortness of breath with exercise and about seizures. Medication use
(prescribed and over-the-counter) should be determined. The family history should focus on
the long QT syndrome, sudden cardiac death or heart attack in members below 35 years of
age and history of Marfan syndrome. Presence of these symptoms or risk factors warrants a
cardiovascular evaluation by a paediatric cardiologist before initiation of therapy.
2. At follow-up visits, patients receiving psychotropic drug therapy should be questioned about
the addition of any drugs and the occurrence of any of the cardiac symptoms. The physical
examination should include checking heart rate and blood pressure.
15
12.
INTERVENTIONS
12.1 Objectives
The followings should be the objectives of any intervention:

To inform child/adolescent and families/carers about the aetiology, diagnosis, and
various management options of ADHD.

To obtain the view of the child/adolescent and families/carers in making the choice of
intervention.

To guide parents/carers to appropriate support groups.
12.2 Information about ADHD
Parents/carers should be informed that ADHD is a neuro-behavioural condition with a strong
genetic aetiology. It involves neurotransmitters and affects certain areas of the brain.
Parents/carers also need to be informed about the reason for comprehensive evaluations
including medical, psychiatric, and cognitive areas, in order for the diagnosis to be made. They
should be explained about the need to rule out other possible diagnoses. Subsequently various
treatment options need to be explored with them.
12.3 Therapeutic Options
The child’s surroundings should be supporting routines and decrease distractions. Consistent
age-appropriate limit setting is important. Retaining a positive, enjoyable relationship with their
child improves his/her self-esteem. Thus, doing things that the child excels at or enjoys is very
important. Parents will need to advocate for the child with schools for appropriate support and
assistance and keep in close and frequent communication with teachers regarding academic
expectations and progress or deficits, as well as social and classroom behaviour.
Parents/carers also need to help the child to develop appropriate social behaviours with peers
and adults outside of school. Parents may have difficulty carrying out the activities outlined
above because they themselves have ADHD and/or another condition (e.g., depression,
anxiety, substance abuse). Other conditions such as medical problems, unemployment, poverty,
single parenthood or marital discord need to be taken into account in working with parents. It is
important to think about possible parental pathology and identify it in order to refer the parent for
appropriate treatment, as without such treatment parents frequently cannot help their child.
Whenever possible, an attempt should be made to work with both parents so that the child
receives the benefit of having the help of each of them, and parents are consistent with each
other in their approaches. Furthermore, sharing this responsibility helps to ensure that one
parent does not become overwhelmed.
13.
TREATMENT OPTIONS
13.1 Psychosocial Therapies
Parents/carers should be informed that children with ADHD may have additional social,
academic, and emotional problems. They may therefore require a variety of
psychosocial/educational interventions, depending upon the need. Interventions such as the
following may be needed for the child and family:
 Additional help with academic progress.
 social skills training.
 individual psychotherapy.
 parent training.
 family therapy.
 lifestyle changes to improve sleep.
13.2 Medication
Parents/carers should be explained in simple language about the advantages and
disadvantages of various available drugs, including short and long-acting stimulants, and non16
stimulant. Concerns and questions parents may have regarding both effects and side effects
need to be addressed with a clear description about common side effects and how these can be
monitored and dealt with? An exploration of what medication can and cannot be expected to do,
and what other interventions should be explained.
13.3 Parents and home situation
While interviewing parents, one needs to obtain a comprehensive knowledge of each parent’s
medical and psychiatric history and past and current level of functioning in various situations
such as occupational, academic, social, and emotional. Particular family situations, such as a
single working parent, separated or divorced parents, or reconstituted families where one or
both parents have remarried, all affect the child with ADHD and the parents’ ability to help their
child. Exploring the family situation is thus crucial to identify problems and address them if they
exist. Relationships between the parents, the parent and child, siblings, and other significant
extended family members (e.g., grandparents, uncles/aunts, stepparents, and stepsiblings),
need to be explored in order to identify strengths and weaknesses in these relationships.
13.4 Parental Psychopathology
It is well known that ADHD runs in families. Parents, siblings, and extended family members
may be affected and therefore have problems with organisation, consistency, impulsivity, and
emotional liability. Substance abuse may also be more common in adults with ADHD. In
addition, having a child with a disability may increase the likelihood of depression and anxiety in
the parents. Parental psychopathology can have a significant impact on the parents’ ability to
structure, monitor, and help their child. Identifying this psychopathology and referring the
parents for appropriate advice and guidance may improve the psychiatric state of the parents
and their parenting ability, and thus be of great help to the child and his/her family.
13.5 PRACTICE POINT:
Make sure to review the child’s strengths, not just his/her areas of weaknesses. This establishes
a rapport with the child and family that makes future visits easier and can aid intervention
planning. If there are any signs or symptoms of a physical illness that may be a factor in
explaining the clinical symptoms, this takes precedence in the evaluation. Begin the interview by
talking about the child’s strengths. The child may not show clinical symptoms in the clinic. If
there are obvious symptoms of hyperactivity, impulsivity and inattention, it suggests that the
symptoms are more severe. Assess whether there are any life events that are of emotional
concern (e.g., abuse, deaths, changes in family dynamics etc). Ask the child to draw a picture of
themselves and then their family on the same page. This helps to determine the child’s
perspective of the family. Note any unusual perceptual differences like drawing themselves
bigger than the parents. Liaise with GP if one or both of the parents needs an assessment for
ADHD or other psychiatric disturbance if it appears evident.
14.
MANAGEMENT OF SOME COMMON PROBLEMS
14.1 Sleep difficulties
Problems with sleep are a common complaint among ADHD patients of all ages. Any decrease
in sleep quality and / or quantity may lead to worsening of behaviour, mood, alertness and level
of concentration. It is therefore important to screen for sleep difficulties. The acronym BEARS is
useful for this purpose:
 Bedtime resistance and delayed sleep onset
 Excessive day time sleepiness
 Awakenings during night
 Regularity, pattern and duration of sleep
 Snoring and other symptoms of sleep-disordered breathing20.
17
The causes of ADHD related sleep problems may include the following:
 Anxiety
 Oppositional Defiant Disorder
 Primary sleep disorders
o Obstructive Sleep Apnoea
o Restless Leg Syndrome
o Delayed Sleep Phase Syndrome
 Stimulant medications may increase the difficulty of falling asleep
Delayed Sleep Phase Syndrome is a sleep disorder which occurs approximately in 7% of
teenagers. Here the teenager falls asleep later than the expected time, has a normal sleep at
night but wakes up late the next day.
Stimulant Induced Insomnia: Administer medication as early as possible in the morning.
Similarly, giving the medication early in the morning and letting him/her go back to sleep allows
the medication to wake him/her up. Try to assure that the patient is not in rebound at the time
that they are trying to fall back asleep, by either lowering he dose late in the day or shaping a
slow offset of action.
14.2 Sleep Hygiene
Optimize sleep hygiene by:
 Maintaining a quiet and comfortable sleep environment.
 Maintaining a consistent time of going to bed and waking in the morning.
 Exposure to activities such as watching television, playing computer games or going on
chat lines will disrupt the initiation of sleep, despite beliefs that these activities promote
fatigue.
 It is helpful if the individual is physically active through the day (though not within two
hours of bedtime) to aid in physical exhaustion.
 Limit the use of the bed to sleep only as this will create a positive association. The bed is
not for watching TV, eating, or doing homework.
 Avoid food or drinks containing caffeine such as chocolate, coffee, tea and cola in the
late afternoon and evening.
14.3 Role of melatonin
Melatonin is a natural hormone produced by the pineal the gland in the brain. It is a sleep
inducer and helps to fall asleep at night. Certain foods are rich in melatonin such as oats, rice,
sweet corn, barley and tomatoes. Foods that are high in tryptophan, a common amino acid
found in many foods including turkey, beans, rice, hummus, lentils, hazelnuts, peanuts, sesame
seeds, sunflower seeds, tuna, soy milk, cow's milk, and other dairy products. Melatonin 2-10 mg
may be administered 30-60 minutes before the bedtime for children with significant difficulty
getting to sleep. We have no available information on the safety and efficacy of melatonin use
on long-term.
14.4 Appetite
Many parents complain that their children are 'picky eaters'. In addition, stimulant medication
further suppresses appetite and often shifts the timing of food intake to periods of the day in
which stimulant blood levels are waning. Early studies of the relationship between special diets,
sugar, food dye, food allergies and ADHD did not confirm that diet is a significant contributor to
the aetiology of ADHD. Children who receive continuous stimulant medication are found to show
growth deceleration as compared to children who do not receive medication for up to three
years, but it is not evident that they end up shorter than control children upon reaching maturity.
Parents who are concerned about their child not eating, eating too much junk food, or refusing
to eat a particular food group are reassured if the time is taken to review dietary intake and
given strategies to encourage good nutrition. In particular children with ADHD may not sit for
18
long meals, may need to snack when medication wears off, and benefit from access to healthy
snacks.
14.5




Strategies to Improve Appetite
Reassure parents that although the child may lose weight, this will stabilize, but the
child's height percentiles will not change. This information helps to reduce parents'
anxiety.
Dry mouth can be a side effect of medication, the patient may have significant thirst.
Allowing them to have frequent fluids throughout the day and high protein/high calorie
drinks for lunch is usually sufficient to maintain their caloric needs. In the evenings when
there may be rebound appetite, supper can be spread out into two or three sessions.
Let the child eat whatever they want for breakfast (e.g. even a peanut butter and jelly
sandwich). Engage the child in meal preparation and in shopping for their favourite
foods.
Switch to whole milk. Prepare nutritious snack foods.
15.
CARE PATHWAY
Appendix 2 is an example of the Care pathway that can be implemented after local
modifications.
16.
SHARED CARE
Appendix 3 is an example of the Shared Care template that can be used in the local Trusts with
appropriate changes, if needed.
19
REFERENCES
1.
National Institute for Health and Clinical Excellence. Attention deficit hyperactivity
disorder. Diagnosis and management of ADHD in children, young people and adults.
Clinical Guideline 72.www.nice.org.uk 2008.
2.
Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit
hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006;36:15965.
3.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, Text Revision. Washington, DC, American Psychiatric Association 2000.
4.
World Health Organization: The ICD-10 classification of mental and behavioural
disorders: clinical descriptions and diagnostic guidelines, World Health Organization
1992.
5.
Canadian ADHD Practice Guideline 2008.
http://www.caddra.ca/cms4/index.php?option=com_content&view=article&id=26&Itemid=
70&lang=en (accessed on 19 April 2010).
6.
Turgay, A. Treatment of comorbidity in conduct disorder with Attention-Deficit
/Hyperactivity Disorder (ADHD) (Special Report). Essential Psychopharmacology, 2005.
6(5): 277-290.
7.
National Institute for Health and Clinical Excellence. Medicines adherence: Involving
patients in decisions about prescribed medicines and supporting adherence. Clinical
guideline 76, 2009. www.nice.org.uk/CG76 9accessed on 18 April 2010).
8.
Charach, A, Ickowicz A, Schachar R. Stimulant treatment over five years: adherence,
effectiveness, and adverse effects. J Am Acad Child Adolesc Psychiatry, 2004. 43(5):
559- 67.
9.
Swanson JM, Elliott GR, Greenhill LL, et al. Effects of Stimulant Medication on Growth
Rates Across 3 Years in the MTA Follow-up. Am Acad Child Adolesc Psychiatry. 2007,
46(8):1015-1027.
10.
American Academy of Child and Adolescent Psychiatry, Practice parameter for the use
of stimulant medications in the treatment of children, adolescents and adults. J Am Acad
Child Adolesc Psychiatry 2007.
11.
American Academy of Pediatrics, Clinical practice guideline: treatment of the schoolaged child with attention-deficit/hyperactivity disorder. Pediatrics, 2001. 108: 1033-1044.
12.
Banaschewski, T, Coghill D, Santosh P, et al. Long-acting medications for the
hyperkinetic disorders: A systematic review and European treatment guideline. Eur Child
Adolesc Psychiatry, 2006. 15(8): 476-95.
13.
National Institute for Health and Clinical Excellence. Attention deficit hyperactivity
disorder: Diagnosis and management of ADHD in children, young people and adults.
Clinical guideline 72. www.nice.org.uk 2008
14.
Scottish Intercollegiate Guidelines Network. Attention Deficit and Hyperkinetic Disorders
in Children and Young People. A national clinical guideline 52. www.sign.ac.uk 2001
15.
Taylor E, Dopfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic
disorder – first update. Eur Adolesc Psychiatry [Suppl 1]. 2004. 13: 1/7- 1/30.
16.
Barkley, R.A., Attention Deficit Hyperactivity Disorder: A Clinical Handbook. Third
Edition. 2005, New York: Guildford Press.
17.
Aman, M.G, Binder C, Turgay A. Risperidone effects in the presence/absence of
psychostimulant medication in children with ADHD, other disruptive behavior disorders,
and subaverage IQ. J Child Adolesc Psychopharmacol, 2004. 14(2): 243-54.
18.
Shea, S, Turgay A, Carroll A, et al. Risperidone in the treatment of disruptive behavioral
symptoms in children with autistic and other pervasive developmental disorders.
Pediatrics, 2004. 114(5): e634-41.
19.
Vetter VL, Elia J, Erickson C, et al. Cardiovascular Monitoring of Children and
Adolescents With Heart Disease Receiving Stimulant Drugs: A Scientific Statement
From the American Heart Association Council on Cardiovascular Disease in the Young
20
20.
Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing.
Circulation, 2008. 117: 2407- 23.
Owens, JA and Dalzell V. Use of the ‘BEARS’ sleep screening tool in a pediatric
residents’ continuity clinic: a pilot study. Sleep Med, 2005. 6(1): 63-9.
21
Appendix 1.
Side-effects Questionnaire (parents/carers)
Child’s Name: ____________________________________D O B
Date_____________________
All medication has side-effects; some are more troublesome than others. We want to make
sure that children who are taking medication do not suffer, even if their work and behaviour
benefit from it.
For each item, please tick in a box on each line how much that word or statement applies to
your child over the last few days according to your own observations
0
1
2
3
4
is not at all
is a few occasions only
is about half the time
is most of the time
is all the time
(not observed)
0
1
2
3
4
(all the time)
Talks less than usual with other children
Poor appetite
Irritable
Complains of stomach ache
Complains of headache
Drowsy
Looks sad, miserable
Looks anxious
Seems unsteady
Excited
Angry
Has nightmares
Displays twitches (tics)
Is there anything else you would like to add?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Thank you very much
22
Appendix 2.
Care pathway
Problems with attention, impulsivity, hyperactivity.
GP, Health visitor, Special Educational Needs Coordinator,
Class Teacher, school nurse
Consider CAF
Referral to ADHD clinic
Mental health
issues identified
ADHD confirmed
Lead professional
CAMHS referral
Refer appropriately
On-going
monitoring in
ADHD clinic
23
Appendix 3
Shared Care Agreement
This shared care agreement describes the responsibilities for both specialist and general
practitioner (GP) in sharing the care and managing the prescribing of ADHD drugs.
Shared care assumes to share the management of the patient including the prescribing of
ADHD drug. This process should begin with a discussion of the process with the patient,
providing an opportunity for the specialist to discuss drug therapy with the patient and carer.
During shared care the specialist will provide regular follow-up and appropriate communication.
RESPONSIBILITIES and ROLES
Secondary Care
 Assessment and diagnosis.
 If diagnosis of ADHD confirmed, measure BP, Height & weight.
 If medication is considered, initiate and titrate to the effective dose, continue treatment
for at least three months.
 Provide information and management options to parents.
 Monitor ADHD symptoms with parents and if possible with teachers.
 Offer other treatment options if needed.
 If patient is stable refer to the GP for shared care.
 Monitor patient yearly and communicate results of review to GP.
Stop medication if ineffective or produces undesirable side effects
Primary Care
 Provide repeat prescriptions.
 Monitor pulse and blood pressure every three months.
 Monitor height and weight every six months.
 Contact the specialist if concerned about any aspects of patient’s treatment.
Refer back to secondary care for:
 Psychological interventions.
 No gain in weight or loss in weight.
 Unmanageable side effects of medication.
 Mental instability.
 Raised pulse, BP and/or cardiac symptoms.
24
Members of the GSF producing these guidelines
Dr Chinnaiah Yemula
Dr Neel Kamal
Dr Somnath Banerjee
With the input from other executive committee members.
25
GSF Executive committee 2010/2011
Advisers:
Prof Nick Spencer
Dr Val Harpin
Chairman:
Dr Geoff Kewley
Convenor:
Dr Somnath Banerjee
Treasurer:
Dr Jayantha Perera
Members:
South England:
Deputy:
Dr Elaine Clark
Dr K Puvanandran
North England:
Deputy:
Dr Hani Ayyash
Dr Neel Kamal
Scotland:
Deputy:
Dr Diana Leaver
Dr Kate Reid
Wales:
Deputy:
Dr Stephen Mackereth
Vacant
Northern Ireland:
Deputy:
Dr Larry Martel
Dr Eleanor Brown
Subcommittees:
Academic:
Chair
Members
Newsletter:
Chair
Members
1.
2.
3.
Dr Hani Ayyash
Dr N Kamal
Dr Cyril De Silva
Dr Diana Leaver
1.
2.
3.
Dr S J Perera
Dr Suresh Nelapatla
Dr Trish Fowlie
Dr Naeem Ashraf
Youth Justice:
Chair
Members
1.
2.
3.
Dr Geoff Kewley
Mrs. Margaret Alsop (associate)
Dr Rashmin Tamhne
Dr Inyang Takon
26
NICE Guidelines Implementation Group:
Chair
Members
1.
2.
3.
Dr Marietta Higgs
Dr Ian Male
Dr C Yemula
Dr Lakshman Doddamani
Trainee rep:
Dr Hamilton Grantham
27