An individualised approach to ADHD management

ADHD is a heterogeneous condition with multiple factors that contribute to the clinical picture.1–5 These include:

  • Age1
  • Gender1
  • Environmental demands2–4
  • Social factors and parenting practices4
  • Psychiatric comorbidities5

 

Each ADHD case is unique and every patient has diverse needs and may respond differently to treatment. Therefore, it is important to take an individualised approach to ADHD management.6–9

Management options

The NICE, CADDRA and German guidelines agree that management of ADHD in children and adults requires a comprehensive, integrated, multimodal treatment plan that may include educational, psychological and pharmacological interventions.6,7,9

Intervention type NICE7 CADDRA9 German guidelines6
Educational Children Adults Individuals with ADHD Individuals with ADHD
Children and their parents should receive ADHD-focused information and group-based support Psychoeducation should be the first intervention Comprehensive psychoeducation should always be offered
Environmental Environmental modifications should be implemented for both children and adults with ADHD Environmental interventions at home and school are recommended
Psychosocial Cognitive behavioural therapy (CBT) may be considered in some young people and adults These can be cognitive or behavioural, and have been shown to reduce impairments associated with ADHD symptoms and improve quality of life as part of a multimodal approach Psychosocial interventions (including psychotherapeutic) should be offered depending on residual symptoms or disease severity
Pharmacological Following a full baseline assessment, medication should only be offered for children aged 5 years* and over and young people if their ADHD symptoms are still causing a persistent significant impairment in at least one domain after their parents have received ADHD-focused information, group-based support has been offered and environmental modifications have been implemented and reviewed Following a full baseline assessment, medication should only be offered to adult ADHD patients if their ADHD symptoms are still causing a significant impairment in at least one domain after environmental modifications have been implemented and reviewed Medications are part of an integrated and multimodal treatment plan that may include educational and psychosocial interventions. As with all pharmacological treatments in medicine, risk/benefit ratios need consideration before initiating any medication Pharmacological treatment can be combined with psychosocial and supplementary interventions in the context of a multimodal treatment plan, according to the individual symptoms, the level of functioning, participation and the preferences of the patient and their social network

 

*ADHD medications are licensed for the treatment of children with ADHD who are aged 6 years and older.
Domains refer to areas of function, for example, interpersonal relationships, education and occupational attainment, and risk awareness.

CADDRA also states that the risk of not treating ADHD should be considered when making the choice on the initiation of medication due to the high morbidity associated with ADHD.9

There are currently two main classes of medication for the treatment of ADHD: stimulants and non-stimulants.6,7,9,10

Individualised pharmacotherapy

In patients who are candidates for pharmacotherapy, 91% respond to stimulants, but a study found that each patient responds differently to medication:11

Summary of responses to methylphenidate (MPH) or amfetamine (AMF) in 318 children and adolescents (mean age 8–10.3 years) from a pooled analysis of 8 randomised studies.11

This means that some patients with ADHD may benefit from an alternative to stimulants.11

References:
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®). Arlington, VA: American Psychiatric Association; 2013:59–65.
  2. Mulligan A, et al. Child Care Health Dev. 2013;39:202–212.
  3. Lasky AK, et al. Soc Sci Med. 2016;161:160–168.
  4. Ellis B, Nigg J. J Am Acad Child Adolesc Psychiatry. 2009;48:146–154.
  5. Hurtig T, et al. Eur Child Adolesc Psychiatry. 2007;16:362–369.
  6. Association of the Scientific Medical Societies in Germany (AWMF) Online. Interdisciplinary Evidence- and Consensus-based (S3) Guideline “Attention-Deficit/Hyperactivity Disorder in Children, Young People and Adults” [in German].
    2018. Available at https://www.awmf.org/uploads/tx_szleitlinien/028-045l_S3_ADHS_2018-06.pdf. Last accessed November 2018.
  7. National Institute for Health and Care Excellence (NICE). Attention Deficit Hyperactivity Disorder: Diagnosis and Management. NICE guideline [NG87]. 2018. Available at nice.org.uk/guidance/ng87. Last accessed November 2018.
  8. Working group of the Clinical Practice Guideline on Therapeutic Interventions in Attention Deficit Hyperactivity Disorder (ADHD). Clinical Practice Guideline on Therapeutic Interventions in ADHD.
    Ministry of Health, Social Services and Equality. Health Sciences Institute in Aragon (IACS) [in Spanish] 2017. Available at http://www.guiasalud.es/GPC/GPC_574_TDAH_IACS_compl.pdf. Last accessed November 2018.
  9. Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition. 2018. Available at https://www.caddra.ca/wp-content/uploads/CADDRA-Guidelines-4th-Edition_-Feb2018.pdf. Last accessed November 2018.
  10. Canadian ADHD Resource Alliance (CADDRA): CADDRA Guide to ADHD Pharmacological Treatments in Canada – 2018. Available at https://www.caddra.ca/wp-content/uploads/Medication_Chart_English_CANADA-3.pdf.
    Last accessed November 2018.
  11. Hodgkins P et al. Eur Child Adolesc Psychiatry. 2012;21:477–492.