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31 Jan 2018

Froehlich TE, Brinkman WB. JAMA Pediatr 2018; 172: 109-110

This review highlights the importance of both pharmacological and non-pharmacological treatment of ADHD in children.

Many children with ADHD have behavioural or developmental comorbidities, and although a child may meet the criteria for ADHD based on the Diagnostic and Statistical Manual of Mental Disorders–5th Edition, no objective measure is currently available that can be used in isolation to diagnose or exclude ADHD. Information on a child’s symptoms and functioning in both a school and home setting using standardised caregiver- and teacher-rating scales is required by the clinician to determine whether a child’s ADHD-like symptoms are due to ADHD. Only once a diagnosis of ADHD has been confirmed can the clinician work with the patient’s family to establish treatment goals and select modalities. Treatment plans involving a patient’s family and interventions that promote shared decision-making to address family concerns (e.g. time, cost, adverse events) are the most successful. The American Academy of Pediatrics guideline for ADHD recommends that clinicians prescribe ADHD-approved medication in combination with evidence-based behavioural therapy. Although stimulant medications produce significant improvements in symptoms, combination therapy with behavioural interventions may allow better results with lower medication dosage.

Psychostimulants are considered the best first-line therapy option for ADHD as they have the highest response rate and effect size (amount of change in symptoms). Gradual escalation titration of ADHD medication is recommended to achieve optimal dosing as no factors have been identified that are consistently associated with ADHD medication response. At present, no reliable pharmacogenetic or neuroimaging tools are available for clinical use in predicting ADHD medication response as an aid in titration. After the initial ADHD medication prescription, telephone calls and email correspondence with families and periodic collection of teacher ratings help to monitor medication response and adverse effects in children with ADHD.

There is little evidence to suggest that one-on-one therapy with a behavioural therapist is effective in managing symptoms of ADHD. Clinicians are instead encouraged to educate families in behavioural parent training (BPT), where the goal is to improve a child’s environment to set the stage for success. BPT is often delivered in small groups, and caregivers are trained to: provide positive reinforcement for appropriate behaviours; set limits; minimise emotionally destructive responses; and implement a behavioural management plan at home between training sessions. Although caregivers often enquire about additional non-pharmacological treatments, therapy in the form of vision training, interactive metronome training, occupational therapy and sensory processing are often unsubstantiated for the treatment of ADHD.

Within a school setting, teacher-implemented strategies, e.g. classroom rules, positive reinforcement for appropriate behaviours and completion/accuracy of work, as well as consequences for rule violations, help reduce the schoolwork-related impairment associated with ADHD. A Daily Report Card intervention implemented by the teacher is also useful in establishing a child’s goals in addition to providing daily feedback on a child’s symptoms and behaviours to their family.

The authors of this review concluded that a combination of medication and behavioural interventions developed in line with the family is the key to successful management of childhood ADHD. It is important that clinicians support communication between families and school services to ensure optimal treatment outcomes for children with ADHD.

Read more about combination therapy options for children with ADHD here

Froehlich TE, Brinkman WB. Multimodal treatment of the school-aged child with attention-deficit/hyperactivity disorder. JAMA Pediatr 2018; 172: 109-110.

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