The aim of the ‘optimal management of ADHD’ process could be described as where an individual patient’s level of symptoms and functional impairment are reduced, quality of life is improved and symptom benefits outweigh any unwanted adverse effects.1-3
This description is supported by some of the European and International guidelines for ADHD and current literature.1-3
‘Optimal management of ADHD’ aims not only to ameliorate patients’ symptoms, but also to reduce functional impairment and improve quality of life.4,5
‘Optimal management of ADHD’ has been described in the literature using such terms as ‘optimal outcomes’, ‘optimising medication effects’ and ‘optimal treatment success’.6-11
Figure: Components of optimal management of ADHD. Figure developed from multiple sources.5-7,9
What would you share with your peers about managing children and adolescents with ADHD from your clinical experience? | Dr Jürgen Fleischmann | Kinderarzte-Netzwerks “päd-Netz”, Rheinland-Pfalz [Paediatrician Network of Rhineland-Palatinate], Germany
From a parents’ perspective, symptom control and their child’s social and academic success may be important treatment considerations.12-14
Patients with ADHD believe that improvements in knowledge and recognition of ADHD as a real disease, combined with a treatment which improves their feeling of ‘normality’ and social acceptance, allows them to reach their potential and meet their goals.15
Lack of knowledge and lack of recognition of ADHD as a real disease are perceived barriers to adult patients with ADHD being accepted in their social environment as individuals with strengths and weaknesses.16
Adult patients with ADHD who receive a diagnosis in adulthood recollect that they had a sense of feeling different from others and had problems in school with learning and in social interactions with classmates and teachers during their childhood.17,18
Some adults remembered feeling that they were:
- Functionally impaired compared with others around them17
- Misunderstood and had stories of bullying, depression, restlessness and drug abuse.18
Many adults have also reported that they felt an earlier diagnosis of ADHD could have led to greater academic achievement and subsequent career success and life experience.18 However, not all adults have reported dwelling on why they felt different; whereas some recognised their deficiencies and wondered about possible causes, others did not acknowledge that they had impairments.17
Adults who are diagnosed with ADHD can also worry that having a ‘disease for life’ would negatively affect their future; however, their acceptance of the disease may allow them to get on with their life.17 Some adults with ADHD report that stimulant medication has a positive influence on their lives, giving them a sense of normality, and allows them to reach their potential and meet their goals.17
How may optimal management of ADHD be achieved?
Due to the heterogeneity of ADHD, the degree of impairment experienced by patients varies depending on personal circumstances. Similarly, not all patients respond to pharmacological or non-pharmacological treatment in the same way. Therefore, although a treatment plan should follow the recommendations of clinical guidelines, it is important to adopt an optimised approach to: identify the unique needs of the patient and their family; agree treatment goals; develop an individualised treatment plan; re-evaluate treatment response; and ensure goals are updated in line with the patient’s needs.1-3,19-23
Figure: The optimal management of ADHD process. Figure developed from multiple sources.1-3,19-23
Considerations for accurate assessment and diagnosis
Assessment and diagnosis can involve the comprehensive evaluation of information gathered from a number of sources, including: clinical examination; clinical interviews; assessment of familial and educational needs; and rating scales.2,20
Accurate assessment and diagnosis requires input from the patient and other observers from across different settings, e.g. at school, work or in the family setting.2,20
Figure: Accurate assessment and diagnosis. Figure developed using information from CADDRA 2018 and NICE 2018 guidelines.2,20 Note that these are examples only and not an exhaustive list.
Communication between the clinician and patient is central to identifying the social, emotional and academic problems experienced by an individual patient with ADHD.1,2 Specific treatment goals should be developed to adequately address the needs and functional impairments of the individual patients.2,20
Figure: Identifying needs. Figure developed using information from CADDRA 2018 guidelines.2
Agreeing treatment goals
Since the impact of ADHD varies between individuals, it is important to incorporate a patient-centred approach by considering patient/family treatment preferences. A solid therapeutic alliance is best achieved by listening to a patient’s concerns and understanding their perspectives and goals.2 A range of psychosocial techniques can be used to target specific areas, e.g. home, school and work.2 Rules, goals, expectations, consequences and incentives should also be simple, clear and limited in number, and close monitoring of successes and failures, ideally with immediate consequences and positive reinforcement, is required to ensure that goals are met.2 The overall purpose of psychoeducation is to educate and empower patients and their families by providing information on ADHD, including how it can impact on daily functioning, treatment options and strategies for optimising functioning.2
Several psychosocial techniques can help patients achieve behavioural treatment goals:2
- Using positive incentives
- Avoiding negative threats
- Utilising reminders
- Creating a structured environment
- Setting clear, attainable goals and limits
- Boosting self-esteem
- Showcasing strengths and talents
- Promoting advocacy.
Individualising a management plan
Each patient must be treated uniquely. Personalised treatment is key to meeting individualised goals.1-3,20-22
The ‘optimal management of ADHD’ process should always consider input from the patient, family/caregivers and school to help establish appropriate therapy (non-pharmacological and/or pharmacological) and goals, resulting in a tailored multimodal treatment plan centred on the patient that addresses multiple aspects of the condition including social, emotional, behavioural and academic or work-related issues.2,19
In adults with ADHD, input from spouses, siblings and friends should be considered.2,19
Figure: It is recommended that a tailored multimodal treatment plan should be centred around the patient. Figure developed using information from international guidelines.1,2,19,20
In your clinical practice how do you develop goals with your patient? | Dr David Coghill | Royal Children’s Hospital, Melbourne, Australia
In your clinical practice, what do you consider when you are developing goals for the patient? | Prof Michel Lecendreux | Hôpital Universitaire Robert Debré, Paris, France
How often do you re-assess progress and re-evaluate goals? | Dr David Coghill | Royal Children’s Hospital, Melbourne, Australia
When developing goals, do you tailor them to specific symptoms? | Dr David Coghill | Royal Children’s Hospital, Melbourne, Australia
Please could you provide some specific examples of goals you have set your patient? | Prof Michel Lecendreux | Hôpital Universitaire Robert Debré, Paris, France
How do you go about setting practical goals? | Professor Peter Hill | Independent Child and Adolescent Psychiatrist, London, UK
Initially, psychoeducation should be available to the individual with ADHD, and to their family and people who interact often with them.2,20,24,25
For children aged <6 years:
- Non-pharmacological interventions are recommended.2,20,24,25
For children/adolescents aged ≥6 years, with moderate ADHD:
- Non-pharmacological interventions are recommended, with medication available for those who request it, or have persisting symptoms.2,20,24,25
For children/adolescents aged ≥6 years with severe ADHD and adults with ADHD:
- Medication is recommended as the first line of treatment, supported by non-pharmacological interventions.2,20,24,25
Read more about current guidelines for ADHD here
In all patient groups, stimulants are usually the first-line treatment for ADHD when pharmacological treatment is indicated. It is recommended that if there are no significant improvements in symptoms then treatment should be reviewed.2,20,24,25
Figure: Optimising ADHD treatment in adults: the updated European Network Adult ADHD guidelines. Figure developed using information from Kooij JJS et al. Eur Psychiatry 2018; 56: 14-34.19
- Whereas some patients may show a treatment response to a given pharmacological treatment, other patients may show an unsatisfactory response.11,26-29
- Patients who do not show a response with initial treatment may derive a benefit from a different therapy either in the same drug class or with a different mechanism of action.27,28
Functional impairment and treatment needs vary throughout the lifespan for many patients. It is important to regularly re-evaluate the ongoing impact of ADHD.2 Patients and their family members or carers should regularly be asked how they want to be involved in treatment planning and decisions; these discussions should take place at intervals to take account of changes in circumstances and development, and should not only happen once.20 Young people receiving treatment for ADHD will require treatment re-evaluation when leaving school to determine the need for continuing treatment into adulthood.20 After transition into adult services, the patient will require a complete reassessment to include personal, educational, occupational and social functioning, as well as consideration of concomitant conditions including drug misuse, personality disorders, emotional problems and learning difficulties.20
Management cycle is stable
Once a patient’s management cycle is stable, a shared-care agreement between primary and specialist care should be adopted to periodically review the patient’s progress.2,20
Figure: Component of a shared-care agreement for ADHD. Figure developed using information from NICE 2018 guidelines.20
- Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder — first upgrade. Eur Child Adolesc Psychiatry 2004; 13(Suppl 1): I/7-I/30.
- Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Fourth Edition. Toronto, ON; CADDRA, 2018.
- Remschmidt H, Global ADHD Working Group. Global consensus on ADHD/HKD. Eur Child Adolesc Psychiatry 2005; 14: 127-137.
- Banaschewski T, Soutullo C, Lecendreux M, et al. Health-related quality of life and functional outcomes from a randomized, controlled study of lisdexamfetamine dimesylate in children and adolescents with attention deficit hyperactivity disorder. CNS Drugs 2013; 27: 829-840.
- Manos MJ. Psychosocial therapy in the treatment of adults with attention-deficit/hyperactivity disorder. Postgrad Med 2013; 125: 51-64.
- Costello EJ, Maughan B. Annual research review: optimal outcomes of child and adolescent mental illness. J Child Psychol Psychiatry 2015; 56: 324-341.
- Baweja R, Mattison RE, Waxmonsky JG. Impact of attention-deficit hyperactivity disorder on school performance: what are the effects of medication? Paediatr Drugs 2015; 17: 459-477.
- Setyawan J, Fridman M, Hodgkins P, et al. Relationship between symptom impairment and treatment outcome in children and adolescents with attention-deficit/hyperactivity disorder: a physician perspective. Atten Defic Hyperact Disord 2015; 7: 75-87.
- Kovshoff H, Vrijens M, Thompson M, et al. What influences clinicians’ decisions about ADHD medication? Initial data from the Influences on Prescribing for ADHD Questionnaire (IPAQ). Eur Child Adolesc Psychiatry 2013; 22: 533-542.
- Spencer TJ, Biederman J, Wilens TE, et al. Novel treatments for attention-deficit/hyperactivity disorder in children. J Clin Psychiatry 2002; 63(Suppl 12): 16-22.
- Hodgkins P, Shaw M, Coghill D, et al. Amfetamine and methylphenidate medications for attention-deficit/hyperactivity disorder: complementary treatment options. Eur Child Adolesc Psychiatry 2012; 21: 477-492.
- Nafees B, Setyawan J, Lloyd A, et al. Parent preferences regarding stimulant therapies for ADHD: a comparison across six European countries. Eur Child Adolesc Psychiatry 2014; 23: 1189-1200.
- Fegert JM, Slawik L, Wermelskirchen D, et al. Assessment of parents’ preferences for the treatment of school-age children with ADHD: a discrete choice experiment. Expert Rev Pharmacoecon Outcomes Res 2011; 11: 245-252.
- Fiks AG, Mayne S, Hughes CC, et al. Development of an instrument to measure parents’ preferences and goals for the treatment of attention deficit-hyperactivity disorder. Acad Pediatr 2012; 12: 445-455.
- Barber S, Grubbs L, Cottrell B. Self-perception in children with attention deficit/hyperactivity disorder. J Pediatr Nurs 2005; 20: 235-245.
- Schrevel SJ, Dedding C, van Aken JA, et al. ‘Do I need to become someone else?’ A qualitative exploratory study into the experiences and needs of adults with ADHD. Health Expect 2016; 19: 39-48.
- Young S, Bramham J, Gray K, et al. The experience of receiving a diagnosis and treatment of ADHD in adulthood: a qualitative study of clinically referred patients using interpretative phenomenological analysis. J Atten Disord 2008; 11: 493-503.
- Brod M, Pohlman B, Lasser R, et al. Comparison of the burden of illness for adults with ADHD across seven countries: a qualitative study. Health Qual Life Outcomes 2012; 10: 47.
- Kooij JJS, Bijlenga D, Salerno L, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry 2018; 56: 14-34.
- NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Accessed February 2019.
- Hodgkins P, Dittmann RW, Sorooshian S, et al. Individual treatment response in attention-deficit/hyperactivity disorder: broadening perspectives and improving assessments. Expert Rev Neurother 2013; 13: 425-433.
- Bolea-Alamañac B, Nutt DJ, Adamou M, et al. Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: update on recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2014; 28: 179-203.
- Scottish Intercollegiate Guidelines Network (SIGN). Management of attention deficit and hyperkinetic disorders in children and young people. 2009. Available at: https://www.sign.ac.uk/assets/sign112.pdf. Accessed February 2019.
- Banaschewski T, Hohmann S, Millenet S. Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im Kindes-, Jugend- und Erwachsenenalter. DGKJP, DGPPN and DGSPJ German guidelines. 2018.
- Guías de Práctica Clínica en el SNS. Grupo de trabajo de la Guía de Práctica Clínica sobre las Intervenciones Terapéuticas en el Trastorno por Déficit de Atención con Hiperactividad (TDAH). 2017.
- Ramtvedt BE, Røinäs E, Aabech HS, et al. Clinical gains from including both dextroamphetamine and methylphenidate in stimulant trials. J Child Adolesc Psychopharmacol 2013; 23: 597-604.
- Efron D, Jarman F, Barker M. Methylphenidate versus dextroamphetamine in children with attention deficit hyperactivity disorder: a double-blind, crossover trial. Pediatrics 1997; 100: E6.
- Arnold LE. Methylphenidate vs amphetamine: comparative review. J Atten Disord 2000; 3: 200-211.
- Newcorn JH, Kratochvil CJ, Allen AJ, et al. Atomoxetine and osmotically released methylphenidate for the treatment of attention deficit hyperactivity disorder: acute comparison and differential response. Am J Psychiatry 2008; 165: 721-730.