ADHD
ADHD is a heterogeneous behavioural syndrome characterised by the symptoms of inattention, hyperactivity, and impulsivity.
Diagnosis DSM-V
The DSM-V recognises three subtypes of the condition
Symptoms must be chronic (lasting at least 6 months), and must be seen in at least 2 or more settings (school, home, or work). Some symptoms must have been present before age 12.
For a diagnosis of predominantly inattentive ADHD there must be at least 6 inattentive symptoms.
For a diagnosis of hyperactive ADHD there must be at least 6 hyperactivity-impulsivity symptoms.
For a diagnosis of combined ADHD there needs to be at least 6 hyperactivity-impulsivity symptoms and at least 6 inattentive symptoms.
Diagnosis ICD-10
The ICD-10 recognises only one form of the condition, which requires symptoms of hyperactivity, inattention, and impulsivity to be present.
General treatment
Pre-school children (<4 years) - Parental training education programmes (basically uses a behavioural model). Drug treatment is not recommended. Group based training programmes developed for the management of children with conduct disorders should be offered.
School age children and young people (4-18 years) [moderate impairment] - group based parent education programmes are first line. Drug treatment is not first line, but may be tried after psychological therapies have been tried.
School age children and young people (4-18 years) [severe impairment] - drug treatment is first line. Group based training can be used as second line.
Medication in children and young people
When drug treatment is considered appropriate, there are a range of options.
Methylphenidate is a CNS stimulant and is first choice for children with ADHD. Children on methylphenidate need to be monitored for growth (height and weight) and blood pressure and heart rate.
Atomoxetine should be used when methylphenidate has been ineffective, where stimulant diversion is an issue, or where dopaminergic adverse effects (e.g. tics, anxiety, stereotypies) become a problem on stimulants. Atomoxetine is associated with suicidal thinking and liver disease.
Dexamfetamine is another CNS stimulant with a smaller evidence base than methylphenidate.
Third-line drugs include clonidine and tricyclic antidepressants. There is some evidence supporting the use of carbamazepine and bupropion. There is no evidence to support the use of atypical antipsychotics. Modafinil appears to be effective.
Medication in adults
Drug treatment is the first-line treatment for adults with ADHD with either moderate or severe levels of impairment. Methylphenidate is the first-line drug.
Psychological interventions without medication may be effective for some adults with moderate impairment, but there are insufficient data to support this recommendation. If methylphenidate is ineffective or unacceptable, atomoxetine or dexamfetamine can be tried. If there is residual impairment despite some benefit from drug treatment, or there is no response to drug treatment, CBT may be considered.
Where there may be concern about the potential for drug misuse and diversion (for example, in prison services), atomoxetine may be considered as the first-line drug treatment for ADHD in adults. Buproprion is another option (Bramble 2012).
Bramble (2012) ADHD with comorbid substance use disorder: review of treatment. Advances in psychiatric treatment, vol. 18, 436-446.
Diagnosis DSM-V
The DSM-V recognises three subtypes of the condition
- Predominately inattentive
- Predominately hyperactive-impulsive
- Combined
Symptoms must be chronic (lasting at least 6 months), and must be seen in at least 2 or more settings (school, home, or work). Some symptoms must have been present before age 12.
For a diagnosis of predominantly inattentive ADHD there must be at least 6 inattentive symptoms.
For a diagnosis of hyperactive ADHD there must be at least 6 hyperactivity-impulsivity symptoms.
For a diagnosis of combined ADHD there needs to be at least 6 hyperactivity-impulsivity symptoms and at least 6 inattentive symptoms.
Diagnosis ICD-10
The ICD-10 recognises only one form of the condition, which requires symptoms of hyperactivity, inattention, and impulsivity to be present.
- i) Hyperkinetic disorder
General treatment
Pre-school children (<4 years) - Parental training education programmes (basically uses a behavioural model). Drug treatment is not recommended. Group based training programmes developed for the management of children with conduct disorders should be offered.
School age children and young people (4-18 years) [moderate impairment] - group based parent education programmes are first line. Drug treatment is not first line, but may be tried after psychological therapies have been tried.
School age children and young people (4-18 years) [severe impairment] - drug treatment is first line. Group based training can be used as second line.
Medication in children and young people
When drug treatment is considered appropriate, there are a range of options.
Methylphenidate is a CNS stimulant and is first choice for children with ADHD. Children on methylphenidate need to be monitored for growth (height and weight) and blood pressure and heart rate.
Atomoxetine should be used when methylphenidate has been ineffective, where stimulant diversion is an issue, or where dopaminergic adverse effects (e.g. tics, anxiety, stereotypies) become a problem on stimulants. Atomoxetine is associated with suicidal thinking and liver disease.
Dexamfetamine is another CNS stimulant with a smaller evidence base than methylphenidate.
Third-line drugs include clonidine and tricyclic antidepressants. There is some evidence supporting the use of carbamazepine and bupropion. There is no evidence to support the use of atypical antipsychotics. Modafinil appears to be effective.
Medication in adults
Drug treatment is the first-line treatment for adults with ADHD with either moderate or severe levels of impairment. Methylphenidate is the first-line drug.
Psychological interventions without medication may be effective for some adults with moderate impairment, but there are insufficient data to support this recommendation. If methylphenidate is ineffective or unacceptable, atomoxetine or dexamfetamine can be tried. If there is residual impairment despite some benefit from drug treatment, or there is no response to drug treatment, CBT may be considered.
Where there may be concern about the potential for drug misuse and diversion (for example, in prison services), atomoxetine may be considered as the first-line drug treatment for ADHD in adults. Buproprion is another option (Bramble 2012).
Bramble (2012) ADHD with comorbid substance use disorder: review of treatment. Advances in psychiatric treatment, vol. 18, 436-446.
