30 Nov 2021

Coghill D et al. Eur Child Adolesc Psychiatry 2021; Epub ahead of print

ADHD is a common neurodevelopmental disorder in children and adolescents; therefore, timely and effective interventions to address core ADHD symptoms and co-occurring problems are a high priority for healthcare and society more widely. Despite considerable research on interventions for ADHD, the research and guidelines for these interventions are sometimes inconsistent and difficult to interpret. This review aimed to critically discuss current clinical evidence on the potential benefits and drawbacks of treatment and management approaches of ADHD, and to consider the limitations of the current evidence base. The focus of this review was on treatment of ADHD in children and adolescents, because a range of both pharmacological and non-pharmacological interventions has been reported in this age range, while the evidence in adults is limited largely due to pharmacological interventions.

Several methodological issues and gaps in the current evidence surrounding ADHD treatment were identified as being important for clinicians to consider when making treatment decisions. These included understanding the potential impact of bias, such as inadequate blinding and selection bias on study outcomes; the relative lack of high-quality data comparing different treatments and assessing long-term effectiveness, tolerability and safety for both pharmacological and non-pharmacological treatments; and the problems associated with observational studies, including those based on large national registries. The latter included limitations such as the potential for referral bias, lack of control for time-varying confounders (Raman et al, 2013), and the lack of information on the validity of diagnoses and explanatory variables when considering the findings.

Data from a network meta-analysis conducted by the European ADHD Guidelines Group (Cortese et al, 2018) were presented in this review, and summarised as supporting general efficacy and tolerability for a broad range of pharmacological treatments for ADHD. The authors of the meta-analysis suggested that methylphenidate in children and adolescents and amphetamines in adults were the preferred first-choice medications for the short-term treatment of ADHD, with regards to combined efficacy and tolerability profiles. However, the authors of this review noted the lack of methodologically sound data on longer-term effectiveness of these interventions. In relation to adverse events and safety, good short-term tolerability of ADHD medications has been reported in the literature; however, the same challenges are acknowledged regarding a lack of evidence on long-term adverse events. The authors suggested that observational studies using large registries and databases are the most effective way to provide complimentary data to that from clinical trials and meta-analyses.

Finally, with regards to non-pharmacological interventions, it is noted that the available evidence surrounding efficacy has been reviewed and analysed in the literature, but not acceptability or adverse events. Parent training is acknowledged as an important complement to the treatment of ADHD, but mainly in relation to reducing additional behavioural problems and improving parent–child relationships. Furthermore, the authors noted that high-quality evidence for neuromodulation in ADHD is limited; in this context, neurofeedback and cognitive training are discussed, and are subsequently not recommended as first-line interventions for the core symptoms of ADHD by this review.

National clinical guidelines for the management of ADHD in children and adolescents from Europe and North America were compared in this review. It was found that there is considerable consensus across different national guidelines, from societies that have diverse rates of acceptance and identification and their organisation of healthcare, for a substantial evidence base for a range of pharmacological and some non-pharmacological treatments, at least in the short term. Despite this consensus, the authors noted that there are significant methodological problems with much of the research upon which these guidelines are based (as mentioned above); clinicians are reminded to be aware of these problems and how they may limit interpretation of the evidence. In addition, they are reminded that different treatment approaches have different mechanisms of action which can impact the duration of action or acceptability, and that different treatments target different areas of impairment.

The authors concluded that, despite the methodological concerns associated with current evidence for ADHD treatments, as discussed in the review, clinicians should be confident that pharmacological treatments for ADHD are mostly effective and well tolerated. They summarised ADHD as an important disorder to treat and manage over time, with a focus on core symptoms, co-occurring problems and improvement of real-world outcomes. It is recommended in the review that clinicians should expect improvement with evidence-based treatment but should undertake this in partnership and with a focus on outcomes that are meaningful for patients.

Read more about the management of ADHD in young people here

Disclaimer: The views expressed here are the views of the author(s) and not those of Takeda.

Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry 2018; 5: 727-738.

Coghill D, Banaschewski T, Cortese S, et al. The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). Eur Child Adolesc Psychiatry 2021; Epub ahead of print.

Raman SR, Marshall SW, Haynes K, et al. Stimulant treatment and injury among children with attention deficit hyperactivity disorder: an application of the self-controlled case series study design. Inj Prev 2013; 19: 164-170.

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