Professor Susan Young

Non-pharmacological treatment approaches for ADHD

Delegates at MoM VIII had options to attend a range of clinical seminars, including one on non-pharmacological and behavioural therapies for ADHD, led by Professor Susan Young (Imperial College London, UK) and Professor Toni Ramos (Vall d’Hebron University Hospital, Barcelona, Spain).

During this seminar, Professor Young discussed how typical non-pharmacological treatment approaches become more direct as patients get older.1

Typical non-pharmacological treatment approaches

Professor Young considered how patients’ thoughts, feelings and behaviours can feed into ADHD symptoms, and explained how adult patients can be supported by coaching on:

  • Positive thinking
  • Breathing techniques
  • Relaxation techniques
  • Behavioural changes that could be tried to see if they lead to positive outcomes
  • Practical approaches that could be implemented to address challenges in everyday life (e.g. use of lists, alarms, diaries, reminders).

In a separate panel discussion, Professor David Coghill (Royal Children’s Hospital, Melbourne, Australia) and Dr Jeffrey Newcorn (Mount Sinai Hospital, New York, USA) described some of the challenges of formally evaluating the effects of cognitive behavioural therapy (CBT), including:

  • Separating the effects of CBT from those resulting simply from the attention given to patients during treatment
  • Determining whether a lack of effect seen in one particular study2 was indicative of CBT’s failure to work or the comparator arm doing unexpectedly well.

Another challenge may be how to select appropriate study endpoints: Professor Philip Asherson (King’s College London, UK) referred to a study of group CBT, which suggested little benefit over clinical management in terms of ADHD symptoms, but he noted that broader benefits were not assessed.2

Professor David Coghill

Pharmacological treatment approaches for ADHD

During a plenary session, Professor Coghill and Dr Newcorn presented information on the four different drug treatments for ADHD (methylphenidate, amfetamine, atomoxetine, guanfacine), including: mechanisms of action, efficacy data, safety data, pharmacokinetic data and dosing. Both Professor Coghill and Dr Newcorn described studies suggesting that some patients with ADHD may respond differently to different drug treatments.3,4 This prompted questions from the audience about how to decide when treatment should be switched.

Overall, there was agreement that switching is recommended when a response is considered sub-optimal despite dose titration, or when tolerability concerns are paramount.

Over the course of the session, the speakers suggested that the following factors could influence appropriate treatment selection:

  • Local treatment guidelines and availability of treatments
  • Clinical trial data – efficacy and safety
  • Clinician experience and preference
  • Patient age, ADHD subtype, comorbidities, treatment history, need for sustained efficacy across the day, and preference
  • Treatment cost and formulation (for patients who are unable to swallow tablets/capsules).

Optimisation of treatment outcomes

Throughout MoM VIII, speakers emphasised the importance of addressing the presenting problems of patients and striving for outcomes that make a meaningful difference to their lives, rather than focusing solely on reductions in symptom scores (although symptom control can be key to improving function and quality of life).

Professor Marina Danckaerts (University of Leuven, Belgium) suggested that some clinicians are ‘satisfiers’ who may not seek optimal treatment outcomes across all problem domains. She called for clinicians to seek optimal responses, beyond symptom improvement.

Professor Danckaerts: “We must invest in seeking optimum treatment response… We need to treat ADHD through careful titration and optimise that treatment to a lot more domains than just symptom improvement.”

  1. Young S, Amarasinghe M. Practitioner review: non-pharmacological treatments for ADHD: a lifespan approach. J Child Psychol Psychiatry 2010; 51: 116-133.
  2. Philipsen A, Jans T, Graf E, et al. Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult attention-deficit/hyperactivity disorder: a randomized clinical trial. JAMA Psychiatry 2015; 72: 1199-1210.
  3. Arnold LE. Methyiphenidate vs. amphetamine: comparative review. J Atten Disord 2000; 3: 200-211.
  4. 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.