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What is ‘optimal management of ADHD’?

‘Optimal management of attention-deficit hyperactivity disorder (ADHD)’, or hyperkinetic disorder (HKD), may be described as the process where an individual’s level of symptoms and functional impairment are reduced, quality of life is improved and symptom benefits outweigh any unwanted adverse effects.1-3 This description is supported by some of the European and international guidelines for ADHD and in the literature.1-3 ‘Optimal management of ADHD’ has been described in the literature using such terms as ‘optimal outcomes’, ‘optimising medication effects’ and ‘optimal treatment success’.4-9

Please note that this information has been taken from multiple sources and is not intended for use to guide diagnosis or treatment.

How may ‘optimal management of ADHD’ be achieved?

A treatment plan for ADHD is recommended to follow clinical guidelines. It is also important for clinicians to adopt an optimised approach to management of ADHD to: identify the unique needs of the individual with ADHD and their family; agree treatment goals; develop a personalised treatment plan; re-evaluate treatment response; and ensure goals are updated in line with the individual’s needs (Figure 1).1-3,10-13

Figure 1: ‘Optimal management of ADHD’ process. Figure developed from multiple sources.1-3,10-13

components-of-optimal-management-of-adhd

‘Optimal management of ADHD’ may be described as a reduction in the level of ADHD symptoms and functional impairment, and an improvement in quality of life such that symptom benefits outweigh any unwanted adverse effects.1-3

Assessment and diagnosis

Assessment and diagnosis of ADHD can involve the comprehensive evaluation of information gathered from a number of sources, including: clinical examination; clinical interviews; assessment of familial and educational needs; and rating scales.2,11 Accurate assessment and diagnosis may require input from the individual with ADHD and other observers from across different settings, e.g. at school, work or in the family setting.2,11

Identifying needs

Communication between the clinician and the individual with ADHD is considered central to identifying any social, emotional, behavioural and academic problems experienced.1,2 It is recommended that specific treatment goals should be developed to adequately address the needs and functional impairments of each individual.2,11

Agreeing treatment goals

The impact of ADHD varies between individuals; therefore, it is important to incorporate a patient-centred approach by considering individual and/or family treatment preferences. A solid therapeutic alliance may best be achieved by listening to an individual’s concerns and understanding their perspectives and goals.2 A range of psychosocial techniques may be used to target specific areas, e.g. home, school and work.2 Rules, goals, expectations, consequences and incentives are recommended to be simple, clear and limited in number, and close monitoring of successes and failures, ideally with immediate consequences and positive reinforcement, may be required to ensure that goals are met.2 The overall purpose of psychoeducation is to educate and empower individuals with ADHD and their families by providing information on ADHD, including how it can impact on daily life, treatment options and strategies for optimising functioning.2

According to the Canadian ADHD Practice Guidelines (CADDRA) 2020 for the diagnosis and treatment of ADHD, several psychosocial techniques may help individuals with ADHD achieve behavioural treatment goals2:

  • Using positive incentives
  • Avoiding negative threats
  • Utilising reminders
  • Creating a structured environment
  • Setting clear, attainable goals and limits
  • Boosting self-esteem
  • Showcasing strengths and talents
  • Promoting advocacy.

Treatment initiation and individualisation

It is recommended that each individual with ADHD should be treated uniquely. Personalised treatment may be key to meeting individualised goals.1-3,11-13 The ‘optimal management of ADHD’ process should consider input from the individual with ADHD, family or carers, and school to help establish goals and appropriate therapy (non-pharmacological and/or pharmacological). In adults with ADHD, input from spouses, siblings and friends may be considered.2,10 A tailored multimodal treatment plan centred on the individual with ADHD should aim to address multiple aspects of the disorder including social, emotional, behavioural and academic or work-related issues (Figure 2).2,10

Figure 2: Guidelines recommend that a tailored multimodal treatment plan for ADHD be centred on the individual. Figure developed using information from international guidelines.1,2,10,11

The optimal management of ADHD process

Guidelines recommend that psychoeducation be initially available to the individual with ADHD, and to their family or carers and the people who interact often with them.2,11,14,15

For children aged <6 years:

For children or adolescents aged ≥6 years and adults with ADHD:

For children or adolescents aged ≥6 years with severe ADHD and adults with ADHD:

  • Pharmacological treatment is recommended as the first line of therapy, supported by non-pharmacological interventions2,11,14,15

Read more about current guidelines for ADHD here.

Stimulants are often the first-line treatment for ADHD when pharmacological therapy is indicated. It is recommended that if there are no significant improvements in symptoms then treatment should be reviewed.2,11,14,15 Additionally, individuals with ADHD may respond differently to distinct pharmacological therapies.9,16-19 Some individuals may show a treatment response to a given pharmacological therapy, whereas others may show an unsatisfactory response.9,16-19 For those who do not show a response with initial treatment, they may derive a benefit from a different therapy either in the same drug class or with a different mechanism of action.17,18

Treatment re-evaluation and reassessment of treatment goals

Functional impairment and treatment needs vary throughout the lifespan for many people with ADHD. It is considered important to regularly re-evaluate the ongoing impact of ADHD.2 It is recommended that individuals and their family members or carers regularly be asked how they want to be involved in treatment planning and decisions; these discussions may take place at intervals to take account of changes in circumstances and development.11 Young people receiving treatment for ADHD may require treatment re-evaluation when leaving school to determine the need for continuing treatment into adulthood.11 After transition into adult services, the individual may require a complete reassessment to include personal, educational, occupational and social functioning, as well as consideration of comorbidities including drug misuse, personality disorders, emotional problems and learning difficulties.11 The availability and approved use of treatments differs between countries. For further information, please consult your local prescribing information.

Management of ADHD is stable

Once an individual’s management of ADHD is stable, a shared-care agreement between primary and specialist care is recommended to be adopted to periodically review the progress.2,11 Recommended components of a shared-care agreement for ADHD by the National Institute for Health and Care Excellence (NICE) 2018 guidelines are outlined in Figure 3.

Figure 3: Recommended component of a shared-care agreement for ADHD. Figure developed using information from NICE 2018 guidelines.11

Non-pharmacological and pharmacological management of ADHD in children and adolescents from CADDRA

  1. Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder – first upgrade. Eur Child Adolesc Psychiatry 2004; 13(Suppl 1): I/7-I/30.
  2. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Edition 4.1. Toronto, ON: CADDRA, 2020.
  3. Remschmidt H, Global ADHD Working Group. Global consensus on ADHD/HKD. Eur Child Adolesc Psychiatry 2005; 14: 127-137.
  4. Costello EJ, Maughan B. Annual research review: optimal outcomes of child and adolescent mental illness. J Child Psychol Psychiatry 2015; 56: 324-341.
  5. Baweja R, Mattison RE, Waxmonsky JG. Impact of attention-deficit hyperactivity disorder on school performance: what are the effects of medication? Paediatr Drugs 2015; 17: 459-477.
  6. Setyawan J, Fridman M, Hodgkins P, et al. Relationship between symptom impairment and treatment outcome in children and adolescents with attention-deficit/hyperactivity disorder: a physician perspective. Atten Defic Hyperact Disord 2015; 7: 75-87.
  7. Kovshoff H, Vrijens M, Thompson M, et al. What influences clinicians’ decisions about ADHD medication? Initial data from the Influences on Prescribing for ADHD Questionnaire (IPAQ). Eur Child Adolesc Psychiatry 2013; 22: 533-542.
  8. Spencer TJ, Biederman J, Wilens TE, et al. Novel treatments for attention-deficit/hyperactivity disorder in children. J Clin Psychiatry 2002; 63(Suppl 12): 16-22.
  9. Hodgkins P, Shaw M, Coghill D, et al. Amfetamine and methylphenidate medications for attention-deficit/hyperactivity disorder: complementary treatment options. Eur Child Adolesc Psychiatry 2012; 21: 477-492.
  10. Kooij JJS, Bijlenga D, Salerno L, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry 2018; 56: 14-34.
  11. NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Accessed January 2021.
  12. Hodgkins P, Dittmann RW, Sorooshian S, et al. Individual treatment response in attention-deficit/hyperactivity disorder: broadening perspectives and improving assessments. Expert Rev Neurother 2013; 13: 425-433.
  13. Bolea-Alamañac B, Nutt DJ, Adamou M, et al. Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: update on recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2014; 28: 179-203.
  14. Banaschewski T, Hohmann S, Millenet S. Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im Kindes-, Jugend- und Erwachsenenalter. DGKJP, DGPPN and DGSPJ German guidelines. 2018.
  15. Guías de Práctica Clínica en el SNS. Grupo de trabajo de la Guía de Práctica Clínica sobre las Intervenciones Terapéuticas en el Trastorno por Déficit de Atención con Hiperactividad (TDAH). 2017.
  16. Ramtvedt BE, Røinäs E, Aabech HS, et al. Clinical gains from including both dextroamphetamine and methylphenidate in stimulant trials. J Child Adolesc Psychopharmacol 2013; 23: 597-604.
  17. Efron D, Jarman F, Barker M. Methylphenidate versus dextroamphetamine in children with attention deficit hyperactivity disorder: a double-blind, crossover trial. Pediatrics 1997; 100: E6.
  18. Arnold LE. Methylphenidate vs. amphetamine: comparative review. J Atten Disord 2000; 3: 200-211.
  19. 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.
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