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17 Jan 2017

Coghill DR. Epidemiol Psychiatr Sci 2016; Epub ahead of print.

There is considerable variability within and between countries in the approach adopted to provide care to patients with ADHD. This review lays out some of the general principles that should be applied across different contexts during the management of ADHD.

The identification of who is best suited to provide care for children with ADHD depends on context-specific considerations such as available medical personnel, the level of their skill, experience and training, the type of patients being referred and the extent of financial assistance available for patients to support their treatment.

Severe cases of childhood ADHD should be managed using a multimodal approach and by a cross-functional team including psychologists, occupational therapists, social workers and specialist nurses to enable the management of core ADHD symptoms along with comorbid conditions. Inclusion of a family therapist is strongly advised, as it educates the family on the best ways to implement other evidence-based treatments.

While less-severe cases of childhood ADHD can be diagnosed and treated by a general practitioner, care should be taken to ensure accuracy of diagnosis including that of comorbidities, comprehensiveness of assessment, and provision of access to a full range of available treatments targeting ADHD (including pharmacological and non-pharmacological therapies), associated impairments and comorbidities.

Other models of care are endorsed by The National Institute for Health and Care Excellence. In the structured stepped pathway, patients with ADHD and their families move between primary and secondary levels of care based on their particular needs and treatment outcomes. In the shared care approach, specialists assume the responsibility of monitoring and adjusting treatments based on their efficacy and adverse effects, while the primary care team is responsible for prescribing medication and providing general care between specialists’ appointments.

It is recommended that patients who continue to experience ADHD symptoms in adulthood be transferred to adult mental health services, and that this transition should be generally completed by the time the patient is 18 years old. Factors that appear to hinder this transition include, among others, difficulties accessing specialist care and support services, lack of patient and caregiver awareness of the necessity for treatment modification during adulthood, reluctance of paediatricians to refer their patients to mental health services, and scarcity of services for adults with ADHD.

Despite the evidence supporting the efficacy of pharmacological and non-pharmacological therapies for ADHD, achieving optimal treatment outcomes remains a challenge. ADHD treatment should aim at improving aspects of the patient’s life beyond ADHD symptoms by focusing on cognitive, functional and quality-of-life outcomes. When medication is used, minimising the emergence of adverse effects is a crucial consideration.

Read more about general recommendations for the effective management of ADHD in children and adults here

 

Coghill DR. Organisation of services for managing ADHD. Epidemiol Psychiatr Sci 2016; Epub ahead of print.

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