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Cover of Evidence reviews for risk factors for ADHD

Evidence reviews for risk factors for ADHD

Attention deficit hyperactivity disorder: diagnosis and management

Evidence review A

NICE Guideline, No. 87

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-2830-9

1. Risk factors for ADHD

1.1. Review question: Which groups of people are more likely than the general population to have ADHD or are more likely to have missed a diagnosis of ADHD?

1.2. Introduction

Although ADHD is a multifaceted condition that has different types of behavioural symptoms, the popular view of symptoms as mainly related to hyperactivity has led to under-diagnosis in certain populations. This chapter looks at the evidence for increased risk of ADHD in certain populations. Here risk refers to populations in which ADHD occurs at higher rates than in the general population, and where practitioners need to be alert to the diagnosis of ADHD.

There are two main reasons to raise awareness of ADHD in populations at high risk of ADHD. First, the overlap of symptoms with other neurodevelopmental and mental health problems can lead to diagnostic overshadowing and a failure to appropriately diagnosis and treat ADHD. Another problem is failure to identify and treat conditions co-existing with ADHD.

The findings on risk are therefore intended to identify the populations in which practitioners need to pay particular attention to the possibility of ADHD. Here screening for ADHD or how best to diagnose ADHD in the presence of co-existing conditions is not considered, the aim is to raise awareness among practitioners of the circumstances under which there is an increased risk of ADHD.

1.3. PICO table

For full details see the review protocol in appendix A.

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

1.4. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual.186 Methods specific to this review question are described in the review protocol in appendix A.

Studies were pooled in this review as default given the lack of importance attached to confounders, however random effects meta-analysis was used to reflect the likely imprecision in effect sizes. Where studies were pooled and substantial heterogeneity was observed, studies were separated and downgraded for inconsistency.

Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy.

1.5. Clinical evidence

1.5.1. Included studies

Sixteen studies were included in the review;13,18,44,51,61,65,81,84,139,155,172,189,225,229,261,286 these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). See also the study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E, GRADE tables in appendix F and excluded studies list in appendix I.

Thirteen studies assessed ADHD diagnosis in childhood (aged 5 to 18) and four studies assessed ADHD diagnosis in adulthood (one study provided information on both children and young people 5 years and over and adults). No studies reported on missed ADHD diagnoses.

1.5.2. Excluded studies

See the excluded studies list in appendix I.

1.5.3. Summary of clinical studies included in the evidence review

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See appendix D for full evidence tables.

1.5.4. Quality assessment of clinical studies included in the evidence review

Table 3. Clinical evidence summary: ADHD diagnosed at age 5 to 18.

Table 3

Clinical evidence summary: ADHD diagnosed at age 5 to 18.

Table 4. Clinical evidence summary: ADHD diagnosed at age >18.

Table 4

Clinical evidence summary: ADHD diagnosed at age >18.

See appendix F for full GRADE tables.

1.6. Economic evidence

1.6.1. Included studies

No relevant health economic studies were identified.

1.6.2. Excluded studies

No health economic studies that were relevant to this question were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in appendix G.

1.7. Resource impact

We do not expect recommendations resulting from this review area to have a significant impact on resources.

1.8. Evidence statements

1.8.1. Clinical evidence statements

ADHD diagnosed at age 5 to 18, there was an increased risk of ADHD diagnosis in children and young people with:

  • Anxiety disorders, two studies of 1877 people (Moderate quality)
  • ODD/CD, three studies of 3502 (Moderate quality)
  • Prematurity, three studies of 897 people (Moderate quality)
  • Substance abuse disorders, two studies of 4394 people (Very low quality)
  • Epilepsy, one study of 73 people (Low quality)
  • ASD, one study of 1585 people (Moderate quality)
  • Mood disorders, two studies of 2716 people (Very low quality)
  • Intellectual disability, two studies of 10666 people (Low quality)
  • Tic disorder, one study of 1596 people (Moderate quality)
  • Family history of ADHD, one study of 153 people (Very low quality)
  • Looked after status, one study of 11691 people (High quality)

ADHD diagnosed at age >18, there was an increased risk of ADHD diagnosis in adults with:

  • Substance abuse, one study of 2466 people, (Low quality)
  • Psychotic disorders, one study of 7325 people, (Moderate quality)
  • Family history of ADHD, two studies of 843 people (Low quality)

1.8.2. Health economic evidence statements

  • No relevant economic evaluations were identified.

1.9. The committee’s discussion of the evidence

1.9.1. Interpreting the evidence

1.9.1.1. The outcomes that matter most

The committee considered increased prevalence rates of ADHD and increased rates of missed diagnoses to be critical outcomes in identifying at risk groups. Identifying groups that have higher rates of ADHD than the general population should raise awareness about people who are likely more likely to have ADHD. Identifying groups with high rates of missed diagnosis will raise awareness about people who are less likely to receive a diagnosis of ADHD, regardless of prevalence. No evidence was identified for the outcome of missed diagnoses.

1.9.1.2. The quality of the evidence

The evidence ranged from moderate to very low quality. The included evidence did not adjust for any confounding factors. This was a deliberate feature of the analysis in the guideline as the aim of the review was not to show causality but to identify risk factors that, in the population seen in primary care, may act as a marker to suggest a higher likelihood of ADHD.

The committee noted that the limitation of this strategy meant that little could be drawn from the magnitudes of association and no statements about causality could be made based on the evidence. The committee also noted that although in some situations no evidence was identified that met the criteria in the protocols to directly answer the research question, there may be existing evidence indirectly supportive of their consensus based recommendations (for example separate studies establishing general prevalence of ADHD and high prevalence of ADHD in specific at risk populations).

The committee agreed that the quality of the evidence was sufficient to make new recommendations to highlight particular groups that may merit increased attention from healthcare professionals to the possibility of exploring an ADHD diagnosis.

1.9.1.3. Benefits and harms

The committee noted that the benefits of identifying groups that are at higher risk of ADHD or having a missed diagnosis of ADHD than the general population would include reducing missed diagnoses and diagnostic overshadowing. This would result in people being offered and receiving treatment appropriate for their ADHD symptoms, reducing impairment and improving their quality of life.

A potential harm of identifying these groups, raising awareness and increasing diagnosis rates is an increase in rates of false diagnoses and some people receiving treatment that is not appropriate.

The committee considered that the benefits outweighed the harms. From the committee’s experience, it is clear quite rapidly if medication for ADHD is effective and so if a false diagnosis had occurred this would be quickly identified and ineffective treatment stopped. The risks of treatment in the short term are relatively low compared to the benefits of more people receiving a correct diagnosis and treatment.

1.9.2. Cost effectiveness and resource use

No economic evidence was identified for this question.

The recommendations in relation to this question are intended to raise awareness about particular populations that may be underdiagnosed or misdiagnosed.

The committee noted that these recommendations have little in the way of costs or harms as they do not recommend a specific intervention and are intended to remind healthcare professionals to be vigilant for the possibility of ADHD or a missed diagnosis of ADHD. There may be an impact from these recommendations if better identification leads on to a diagnosis of ADHD and then there is a potential resource use associated with specialist diagnoses and treatments for ADHD being initiated. Identifying misdiagnosis has the potential to be cost neutral, if the treatments that are stopped and the appropriate ones initiated have similar costs and resource use.

1.9.3. Other factors the committee took into account

The committee noted that girls and women are less likely to present with hyperactivity symptoms and co-existing disruptive conditions, as a consequence they are less likely to be identified and referred for assessment than boys. The committee discussed that the current diagnostic criteria are derived from predominantly male samples and that could be one reason why fewer girls/women are referred, Girls and women with ADHD can have poor social skills with resulting social isolation leading to a negative impact of their self-esteem and well-being. The committee therefore made a separate recommendation for healthcare professionals to be aware of this based on their experience.

Within the recommendations, the committee used the term ‘people known to the Youth Justice System or adult Criminal Justice System’ whereas the protocols and evidence review used ‘people known to the secure estate’. Specific referral to the justice systems was agreed to be a more appropriate term for guidance.

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Appendices

Appendix B. Literature search strategies

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual, Oct 2014, updated 2017

https://www.nice.org.uk/guidance/pmg20/resources/developing-nice-guidelines-the-manual-pdf-72286708700869

For more detailed information, please see the Methodology Review.

B.1. Clinical search literature search strategy

Searches for this review were run in Medline (OVID), Embase (OVID), the Cochrane Library (Wiley). and PsycINFO (ProQuest]. Filters were applied where appropriate.

Table 7. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

Cochrane Library (Wiley) search terms

PsycINFO (ProQuest) search terms

B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting a broad search relating to ADHD population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional searches were run on Medline and Embase.

Table 8. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

NHS EED and HTA (CRD) search terms

Appendix D. Clinical evidence tables

Download PDF (293K)

Appendix H. Health economic evidence tables

None.

Appendix I. Excluded studies

I.2. Excluded health economic studies

None.

Final

Prognostic evidence review

These evidence reviews were developed by the National Guideline Centre

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2018.
Bookshelf ID: NBK578094PMID: 35192257

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