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Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, 4th Edition

The Canadian ADHD Practice Guidelines for the diagnosis and treatment of ADHD received a major update in the first quarter of 2018. These guidelines are produced and funded by the Canadian ADHD Resource Alliance (CADDRA), a national, independent, not-for-profit association made up of healthcare professionals across multiple related specialities. With previous editions published in 2006, 2008 and 2011, the current guidelines (4th Edition) are a product of constant review against newly published research in ADHD, 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 have been designed to be easily accessible and simple to use. Please note that while this synopsis provides a brief overview of some of the updated recommendations in the 4th Edition 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 patients. Healthcare professionals should consult the full CADDRA guideline document, which is available on the CADDRA website.

In summary, Chapters 1 and 2, which cover the diagnosis of ADHD as well as differential diagnosis and comorbid disorders, have received minimal alterations in this 4th Edition update. However, a new Chapter 3 entitled “Special considerations across the lifespan” now highlights specific issues and factors from childhood (pre-school and school age) through to adolescence, adulthood and older adulthood, whereas in previous editions this was discussed in separate chapters for each age group (child, adolescent, adult). Chapters 4 and 5 on the psychosocial and pharmacological management of ADHD have been expanded upon and guidance has been significantly updated, and there is a new Chapter 6 entitled “Treatments requiring further research”, which looks at 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.

This update brings the guidelines further in line with the evidence that ADHD is a persistent disorder that results in impairment of varying levels throughout many patients’ lifespans. For example, Chapter 3 highlights special factors to consider 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 updated guidelines also discuss the impact that ADHD may have across all areas of life, examining the effects on the individual, the family as a whole, school and education, work life, and healthcare and societal effects.

The updated guidelines continue to maintain that ADHD requires a comprehensive, collaborative and multimodal treatment approach, including both psychosocial and pharmacological treatment options where appropriate. Chapter 4 describes how psychoeducation can help people with ADHD, discussing the key actions to take when treating a person with 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 can best be implemented in the home, at school and in the workplace.

Chapter 5 examines the pharmacological side of treatment to complement psychosocial approaches where beneficial. As noted previously, the summary of treatment recommendations below is an overview of some of the updated treatment recommendations in the revised CADDRA guidelines. This overview is not exhaustive of all recommendations and should not be used as the basis to treat patients. 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 approach:

  • Step 1: Setting treatment objectives
    • Following diagnosis, ADHD symptoms and functional challenges (across home, school and/or work) need to be identified as treatment targets.
    • Treatment objectives should be set that are ‘Specific, Measureable, Attainable, Relevant and Timely’ (SMART).
  • Step 2: Medication selection
    • Patient-related factors to consider include: age and individual variation; duration of effect required by timing of symptoms; concurrent psychiatric and medical issues; and physician, family and patient attitudes.
    • Medication-related factors to consider 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 include: combining medication for adjunct effects; generic formulations; and potential for abuse, misuse and diversion.
  • Step 3: Titration and monitoring
    • Take a structured approach to measuring treatment response, 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-up
    • Long-term follow-up of individuals with ADHD should involve:
      • Proactive integrated care with active involvement from patients.
      • 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.

Concluding the section on current treatment of ADHD, the guidance follows up the stepped approach to prescribing with an updated look at 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).

The 2018 update to the CADDRA ADHD Practice Guidelines provides a refreshed look at the diagnosis and management of ADHD in different age groups. The guidelines provide clinically applicable recommendations and retain the extensive toolkit from the previous edition to assist both primary care physicians and specialists in optimising treatment of people with ADHD throughout the lifespan.

Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018.

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