The Canadian ADHD Practice Guidelines for the diagnosis and treatment of ADHD were published in 2020. These guidelines are produced and funded by the Canadian ADHD Resource Alliance (CADDRA), a national, independent, not-for-profit association comprised of healthcare professionals across multiple related specialities. With previous editions published in 2006, 2008, 2011 and 2018, the current guidelines (4.1 Edition) are a product of constant review against newly published research in attention-deficit hyperactivity disorder (ADHD), or hyperkinetic disorder (HKD), and were assembled and refined by a multidisciplinary team involving ADHD specialists, paediatricians, psychiatrists, psychologists, primary care physicians, pharmacists, nurses and educators from across Canada. These guidelines are consensus-based and have been designed to be easily accessible and simple to use.1 Please note that while this synopsis provides a brief overview of some of the recommendations in Edition 4.1 of the CADDRA guidelines on the diagnosis and management of ADHD, this is not exhaustive of all recommendations and should not be used for the diagnosis or treatment of ADHD. Healthcare professionals should consult the full CADDRA guideline document, which is available on the CADDRA website.
These guidelines are directed at healthcare professionals in Canada, some of the medications recommended may not be approved in other countries.
Chapters 1 and 2 of the CADDRA guidelines 2020 include diagnosis of ADHD, differential diagnosis and comorbid disorders. Chapter 3 highlights specific issues and factors from childhood (pre-school and school age) through to adolescence, adulthood and older adulthood. Chapters 4 and 5 describe psychosocial and pharmacological management of ADHD, and Chapter 6 includes treatments that still require further research before any recommendations for their use can be made, such as omega-3 fatty acids, nutritional supplements, neurofeedback and chiropractic care.1
The CADDRA guidelines 2020 state that ADHD is a persistent disorder that may result in impairment of varying levels throughout the lifespan. For example, Chapter 3 highlights special factors that may be considered in each age group, from prevalence to under-diagnosis in specific subpopulations, typical treatment adherence, accident rates and other risks, along with other specific points of interest. The impact that ADHD may have across all areas of life, including the effects on the individual, the family as a whole, school and education, work life, and healthcare and societal effects are also described.1
The CADDRA guidelines 2020 highlight that ADHD requires a comprehensive, collaborative and multimodal treatment approach, including both psychosocial and pharmacological treatment options, where appropriate. Chapter 4 describes how psychoeducation may help people with ADHD, discussing the key actions that can be taken when treating ADHD: discover, demystify, instil hope, educate, empathise, encourage, guide and motivate, show cultural and gender sensitivity, promote a balanced lifestyle and provide resources. Specific interventions are examined, looking at how they may be implemented in the home, at school and in the workplace.1
Chapter 5 examines pharmacological treatment to complement psychosocial approaches where beneficial (Figures 1 and 2). As noted previously, the summary of treatment recommendations below is an overview of some of the updated treatment recommendations in the CADDRA guidelines 2020. This overview is not exhaustive of all recommendations and should not be used as the basis to treat ADHD. Please refer to the complete CADDRA guideline document available on the CADDRA website. Chapter 5 opens with an overview of first-, second- and third-line treatments, before discussing pharmacological prescribing in a stepped approach1:
Step 1: Setting treatment objectives1
- Following diagnosis, it is recommended that ADHD symptoms and functional challenges (across home, school and/or work) are identified as treatment targets. Treatment objectives are recommended to be set that are ‘Specific, Measurable, Attainable, Relevant and Timely’ (SMART).
Step 2: Medication selection1
- Individual-related factors to consider may include: age and individual variation; duration of effect required by timing of symptoms; concurrent psychiatric and medical issues; and physician, family and individual attitudes.
- Medication-related factors to consider may include: active ingredient/mode of action/drug interactions; delivery system/onset of action/duration of action; available doses; Canadian clinical indications; and affordability, accessibility and reimbursement.
- Special considerations may include: combining medication for adjunct effects; generic formulations; and potential for abuse, misuse and diversion.
Step 3: Titration and monitoring1
- Taking a structured approach to measuring treatment response is recommended, including:
- Informal and formal observation and rating of improvements.
- Regular contact and check-ups during the titration period.
- “Start low and go slow”; increase the dose until desired treatment goals have been reached, or side effects preclude dose increases, or the maximum recommended dosage has been reached.
Step 4: Ongoing follow-up1
- Long-term follow-up of individuals with ADHD are recommended to involve:
- Proactive integrated care with active involvement from the individual.
- Multimodal treatment (non-pharmacological plus pharmacological treatment).
- Provision of ongoing education on the management of ADHD to healthcare professionals, teachers and other stakeholders.
- Access to specialist expertise when required.
Figure 1. Non-pharmacological and pharmacological management of ADHD in children and adolescents. Figure developed using information from CADDRA – Canadian ADHD Resource Alliance: Canadian ADHD Practice Guidelines, 4.1 Edition, Toronto ON; CADDRA, 2020.1
Figure 2. Non-pharmacological and pharmacological management of ADHD in adults. Figure developed using information from CADDRA – Canadian ADHD Resource Alliance: Canadian ADHD Practice Guidelines, 4.1 Edition, Toronto ON; CADDRA, 2020.1
Concluding the section on current treatment of ADHD, the CADDRA guidelines 2020 includes information on side-effect management (common side effects and their management, and when/how to reduce/stop/change treatment), how to approach an unsatisfactory response to treatment (DATER: Dosage, All options explored, Time, Examine, Review), and detailed information on the medications approved for treatment of ADHD in Canada (such as brand name, indication, dosages available and notes from the CADDRA Guideline Committee).1
- Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Edition 4.1. Toronto, ON: CADDRA, 2020.