Summary of Treatment Guidelines for ADHD

AAP Treatment Recommendations Nov 2019

		First-line	Second line
Preschool children (4-5 years)		Behaviour therapy	Methylphenidate
	Methylphenidate, if no significant improvement and moderate-to-severe functional impairment
Elementary school (6–11 years)		Behaviour therapy or medication, preferably both.
Evidence		stimulants > atomoxetine > guanfacine ER > Clonidine ER

Summary, NICE Treatment Recommendations 2018

	First-line	Second line
Children under 5 years	Discussion Group parent-training program (ADHD-Focused)	Medication (Only a specialist can start)

Start medications only after seeking advice from ADHD specialist services

Children over 5 years	Discussion and ADHD-focused Support	Medication
Support Offer a minimum of 1 or 2 sessions of support, can be group-based	education on the causes and impact of ADHD advice on parenting strategies liaison with school, parents, and carers
Discussion Before starting treatment, discuss with the carers	The benefits of a healthy lifestyle, including exercise The benefits and harms of non-pharmacological and pharmacological treatments Their preferences and concerns How other conditions affect treatment choices	Importance of treatment adherence Record the person's preferences and concerns Ask if they wish a carer to join discussions Reassure that they can revisit decisions
Medication Children over 5	Methylphenidate	Lisdexamfetamine, after 6weeks trial off the methylphenidate

Justpsychiatry

Correspondence justpsychiatry@outlook.com

A 9-year-old child presented to you in the outpatient department, brought by his mother who was concerned because of his poor performance at school, saying his brother and sister are much more competent. On enquiry, she revealed that the child seems absent-minded, repeatedly loses items, does not seem to listen when being talked to, is fidgety and keeps running and bouncing ‘as if driven by a motor.’ His academic report revealed ‘below-average performance’ and he scored of 90 Weschler intelligence scale for children. The rest of the assessment was unremarkable.

What would be your recommendation?

Atomoxetine

Clonidine

Methylphenidate

Lisdexamfetamine

Psychosocial Interventions

The scenario best depicts a mild case of attention deficit hyperactivity disorder (ADHD).

Most patients will need psychosocial interventions and medications combined. However, the National Institute of Clinical Excellence recommends psychosocial interventions as the first choice of therapy. American Academy of paediatrics recommends psychosocial interventions as a primary treatment strategy for preschool children (4-5 years of age) and combined psychosocial and pharmacological treatments for older children. Both NICE and AAP recommend methylphenidate as the preferred medication if you must start one. Similarly, Canadian guidelines for the management of ADHD recommend psychosocial interventions before a trial of medication. They recommend methylphenidate and lisdexamfetamine as first-line medication. Nonetheless, patient individualization is important. For instance, if a patient has a comorbid tic disorder, clonidine will treat both the tic disorder and symptoms of ADHD, while stimulants may worsen the tics. Likewise, a patient with comorbid conduct disorder will need other specific interventions.

The best answer would be psychosocial interventions. Please let us know your thoughts. We have summarized the Recommendations of AAP and NICE on the next page.

References

Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD practise guidelines (CAP-guidelines) [Internet]. 3rd. Toronto: CADDRA; 2011.

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Paediatrics. 2011;128(5):1007-1022. doi:10.1542/peds.2011-2654

Overview | Attention deficit hyperactivity disorder: diagnosis and management | Guidance | NICE. (2018). Retrieved from https://www.nice.org.uk/guidance/ng87

Justpsychiatry

Correspondence justpsychiatry@outlook.com

Which one of these disorders can not coexist with Hyperactivity disorder (according to ICD classification)?

Anxiety disorder
Depression
Autism
Conduct disorder

ICD-11 Criteria for Single Episode Depressive Disorder (Depressive Episode) (6A70)

ICD-11 Criteria for Single Episode Depressive Disorder (Depressive Episode) (6A70) Single episode depressive disorder is characterised by the presence or history of one depressive episode when there is no history of prior depressive episodes. A depressive episode is characterised by a period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder. Exclusions: Recurrent depressive disorder (6A71) Adjustment disorder (6B43) Bipolar...

ICD-11 Criteria for Depression (Recurrent Depressive Disorder) 6A71

ICD-11 Criteria for Depression (Recurrent Depressive Disorder) 6A71 Recurrent depressive disorder is characterised by a history or at least two depressive episodes separated by at least several months without significant mood disturbance. A depressive episode is characterised by a period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a Bipolar disorder. Inclusions: Seasonal depressive disorder Exclusions: ...

ICD-11 Criteria for Bipolar Type-1 Disorder

ICD-11 Criteria for Bipolar Type-1 Disorder 6A60 Bipolar type I disorder is an episodic mood disorder defined by the occurrence of one or more manic or mixed episodes. A manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention characterised by euphoria, irritability, or expansiveness, and by increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behaviour, and rapid changes among different mood states (i.e., mood lability). A mixed episode is characterised by the presence of several prominent manic and several prominent depressive symptoms consistent with those observed in manic episodes and depressive episodes, which either occur simultaneously or alternate very rapidly (from day to day or with...

Search This Blog