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
‘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
Components of optimal management of ADHD
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 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.15
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.16,17 Adults who are diagnosed with ADHD can 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.16 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.16
How could optimal management of ADHD be achieved?
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 pharmacological), goals and assessment/follow-up, resulting in a tailored multimodal treatment plan centred on the patient.1-3,18,19
The optimal management of ADHD process1-3,18-22
Accurate assessment and diagnosis
Assessment and diagnosis involves the comprehensive evaluation of information gathered from a number of sources, including: clinical examination; clinical interviews; assessment of familial and educational needs; and assessment tools and rating scales.1,18,19,23,24
Accurate assessment and diagnosis always requires input from the patient and other affected individuals, such as parents, carers, family members and teachers for children and adolescents with suspected ADHD; and spouses, siblings, friends, co-workers and employers for adults with suspected ADHD.1,18,19,23,24
Accurate assessment and diagnosis
To identify the needs of the patient and their family, several aspects of their life must be dealt with through a multimodal approach that addresses the social, occupational, emotional, behavioural and academic issues.1,2
Agreeing treatment goals
Since the impact of ADHD varies between individuals, specific treatment goals should be developed to adequately address the needs of each patient and their family.2,3,20
A structured environment, in which expectations and goals are consistent and structured, is likely to help patients with ADHD function optimally.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 no more than two target behavioural treatment goals at the same time
- Boosting self-esteem
- Showcasing strengths and talents
- Promoting advocacy.
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
Collaborative, multimodal care
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 pharmacological) and goals, resulting in a tailored multimodal treatment plan centred on the patient.1,2,18,19
European, Canadian and UK guidelines for the treatment of ADHD recommend a comprehensive, collaborative, multimodal approach to treatment tailored to meet the unique needs of each individual.1,2,18,19
Optimal management of ADHD: collaborative, multimodal care
Initially, psychoeducation should be available to the individual with ADHD, and to their family and people who interact often with them.1-3,18,19,21
For children aged <6 years:
- Non-pharmacological interventions are recommended.1,3,18
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.1,3,18,19,21
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.1-3,18,19,21
In all patient groups, stimulants are usually the first-line treatment for ADHD when pharmacological treatment is indicated.1-3,18,19,22 It is recommended that if there are no significant improvements in symptoms then treatment should be reviewed.1,2,18
Optimising ADHD treatment in children: an example treatment algorithm from ESCAP guidelines. Reproduced with kind permission.1
Optimising ADHD treatment in adults: The European Network Adult ADHD guidelines. Reproduced with kind permission.19
Patients with ADHD may respond differently to different pharmacological treatments:11,25-28
- Whereas some patients may show a treatment response to a given pharmacological treatment, other patients may show an unsatisfactory response11,25-28
- 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.26,27
Patients’ needs will change as they progress through the different stages of life; therefore it is important to periodically re-evaluate the alignment of treatment goals to the current needs of the patient.2 Once the symptoms of ADHD have been effectively managed, longer-term treatment plans may need adapting to address any residual co-existing problems.18 Young people receiving treatment for ADHD will require treatment re-evaluation when leaving school to determine the need for continuing treatment into adulthood.18
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.2,18,21
Component of a shared-care agreement for ADHD21
- 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. Toronto: CADDRA, 2011.
- Remschmidt H. 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.
- 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.
- National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/cg72/resources/attention-deficit-hyperactivity-disorder-diagnosis-and-management-975625063621. Last updated 2016. Accessed 05 January 2017.
- Kooij SJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 2010; 10: 67.
- 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. Available at: http://www.sign.ac.uk/pdf/sign112.pdf. Last updated 2009. Accessed 06 January 2017.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013.
- World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Available at: www.who.int/entity/classifications/icd/en/bluebook.pdf. Last updated 1993; 1: 1-263. Accessed 04 January 2017.
- Ramtveldt BE, Røinäs E, Aabech HS, et al. Clinical gains from including both dextroamphetamine and methylphenidate in stimulant trials. J Child Adolesc Psychopharmacol 2013; 23: 587-604.
- 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.