Approach

Attention deficit hyperactivity disorder (ADHD) often affects many areas of functioning, including school, family relationships, friendships, activities, and self-esteem. Psychoeducation is a first-line intervention for all patients.[111]​ Treatment should be comprehensive and multimodal as well as flexible over time as presenting symptoms and necessary supports will change as development progresses. Key aims clinically are to maximise functioning, and improve overall quality of life.[111] Patients should be monitored with regular follow-up to monitor target symptoms, outcomes, and adverse effects.​[90]​​[91]

The treatment approach suggested here is derived from US, Canadian, and UK guidance, and from an international consensus statement.[90][91][92][111]​ A key difference in practice internationally is that US guidance recommends consideration of medication immediately following diagnosis, whereas UK guidance recommends beginning with a ‘watchful waiting’ approach with psychoeducation and behavioural management, particularly for children with mild symptoms and impairment.[91] For children under the age of 6 years (or 5 years in the UK) there is international consensus that treatment should start with behavioural management in the form of parent training, and that pharmacological treatment should only be considered when initial treatment is unsuccessful.[90][91]

Overall, for school-age children there is some evidence that pharmacological treatment is more effective than psychosocial treatment. In the landmark Multimodal Treatment Study of AD/HD trial (MTA), the largest trial comparing stimulants with behavioural therapy in ADHD, stimulants prescribed with regular follow-up appeared to be superior to behavioural therapy after 14 and 24 months.[112][113][114]​​ Although the MTA data suggest that this advantage disappears at 36 months, there is controversy about whether this simply reflects factors in the study design rather than an inherent loss of stimulant efficacy with time.[112][113][114]

Treatment should be designed for the individual patient so that efficacy, tolerability, compliance, and affordability are maximised.[91] Treatment decisions should be made on a risk:benefit calculation which weighs the risks of medication against the risks of no pharmacological intervention. Note that regardless of specific local guideline recommendations, non-pharmacological treatments may be preferred by some patients and their families over medication, at least initially. If pharmacological treatment is indicated, psychosocial interventions are recommended as an adjunct. In practice, pharmacological treatment may help children make better use of behavioural strategies by improving focus and decreasing impulsivity and hyperactivity.[115]​​ Psychosocial interventions may play a particularly important role during key life transitions, for example, from adolescence to adulthood.[111]

Individual factors to consider when determining treatment include:[111]

  • Age (behavioural management is recommended for young children under the age of 6 years)

  • Duration of effect required by timing of symptoms

  • Concurrent psychiatric and medical conditions

  • Available medications, doses, and preparations as dictated by location of practice

  • Any potential for stimulant abuse, misuse, or diversion

While there is no specific evidence for a familial pattern to the response to treatment with stimulant medicines, clinical experience suggests that determining the experience of any family members to specific medicines can help identify positive or negative experiences that are worth considering in the choice of which specific medicine to use or not use.

Stimulant medications are the first line of pharmacological treatment for children older than pre-school age, followed by atomoxetine, and/or alpha-2-adrenergic agonists (guanfacine and clonidine). Stimulants have a larger effect size than non-stimulant medications.[116]​ The American Academy of Pediatrics note that the evidence is particularly strong for stimulant medications; they note that it is sufficient, but not as strong, for atomoxetine, extended-release guanfacine, and extended-release clonidine, in that order.[90]

In some countries, such as the UK, pharmacological management should only be initiated and coordinated by specialists (e.g., child and adolescent psychiatrists, paediatrician or other specialist in ADHD in children), although treatments may be continued and monitored in primary care depending on locally agreed arrangements.[117] In other countries, such as the US, pharmacological treatment may be initiated in either primary or secondary care depending on the training/experience of the primary care provider, although specialist input is recommended if there is clinical complexity (e.g., presence of comorbidities) or if initial treatment is ineffective.[90]

Pre-school-aged children (4-6 years)

There is international consensus that psychosocial intervention with parent training in behaviour management (PTBM) and/or behavioural classroom interventions are the first-line treatment in this age group.[90][91]​ The aim of parent training is to help parents improve their understanding of the child's behaviour; it also teaches skills to manage it better (such as directive communication skills, reinforcing positive behaviours, time out techniques, establishing a home token economy, and anticipating non-compliant behaviours). A formal diagnosis of ADHD is not required before recommending parent training given that it has documented effectiveness for problematic behaviours regardless of aetiology; instead, it is typically recommended that parents should not wait for an ADHD diagnosis before initiating the treatment.[90] Specific types of parent training vary according to location of clinical practice; for example group-based parent training is recommended by the National Institute for Health and Care Excellence in the UK.[91] One RCT looking at pharmacological treatment for pre-school children with an established diagnosis of ADHD found that, following parent training, around one third of children had experienced a significant improvement in symptoms to the extent that they did not require medication at that time.[118]​ The Incredible Years (IY) basic parent training (PT) programme has been shown to be a valuable intervention for preschool children with early signs of ADHD.[119] [ Cochrane Clinical Answers logo ]  Discussions can also include referral to support and advocacy organisations.​ ADHD UK Opens in new window​​ Online resources and toolkits such as parent handouts and rating scales are available. Vanderbilt ADHD diagnostic scales Opens in new window ADDitude magazine Opens in new window

If behavioural interventions do not provide significant improvement, and symptoms are persistent, moderate-to-severe in severity, and consistent across home and other settings, a specialist clinician must weigh up the risks of starting medication before the age of 6 years versus the harm of delaying treatment. This decision should only be made with input from a mental health specialist with specific experience with pre-school-aged children, ideally one working within a tertiary service.[90][91] There is evidence to suggest that adverse effects are more common in this age group.[118]​ If pharmacological treatment is required, methylphenidate is the recommended treatment for children aged 4 and 5 years given that it has the strongest evidence compared with other treatments for this age group, although the evidence has not yet met the threshold required for US Food and Drug Administration (FDA) approval, and it is used on an 'off-label' basis.[90] There is moderate evidence that methylphenidate is safe and effective in this age group, based on one multi-site study (n=165) and a number of other smaller studies.[118][120]​ Pre-school children (<6 years of age) treated with methylphenidate generally require a lower dose and manifest more emotional adverse effects (irritability, tearfulness) than school-aged patients. Additionally, the effect size of the stimulant medication is smaller in pre-school children.[118]

In US practice, up to 25% of pre-school children with ADHD are treated with an alpha-2-adrenergic agonist (such as guanfacine) despite limited evidence regarding safety and efficacy in this age group.[121] There is preliminary evidence from one US retrospective study to suggest that use of alpha-2-adrenergic agonists may be associated with reduced rates of irritability/moodiness compared with stimulants (29% vs. 50%), with improvement in ADHD symptoms reported in 66% of children taking an alpha-2-adrenergic agonist versus 78% of children taking a stimulant.[121] This offers a limited degree of support for the preference among some specialists to consider guanfacine for pre-school children with predominant symptoms of irritability and oppositionality, although further evidence (including RCT evidence) is required as to the safety and efficacy of this approach, and methylphenidate remains the first-line option in pre-school children if pharmacological treatment is required.

School-aged children (6-18 years): psychoeducation

The patient and family should be educated about symptoms, typical course, and potential treatments. These discussions should include coaching about educational services and adaptations. Discussions can also include referral to support and advocacy organisations.​ ADHD UK Opens in new window​​ Online resources and toolkits such as parent handouts and rating scales are available. Vanderbilt ADHD diagnostic scales Opens in new window ADDitude magazine Opens in new window​​ Information on treatment options and should consist of clear, non-technical language and evidence-based recommendations.

School-aged children (6-18 years): stimulant medications

Stimulant medications (drugs based on methylphenidate and amfetamine) are the first-line pharmacological agents of choice for children above pre-school age.[122] UK guidance recommends starting with methylphenidate if pharmacological treatment is required, and switching to an amfetamine if the initial response is inadequate.[91] US guidance lists stimulants as the first-line option but does not specify a particular stimulant to try first.[90]

Efficacy of stimulants

Amfetamines and methylphenidate have been shown to be effective at improving the core symptoms of ADHD compared with placebo.[116][123][124]​​​​​​[125]​​​​​ [ Cochrane Clinical Answers logo ] ​​​​​​​​​​​ The majority of patients, between 60% and 75%, respond to an initial stimulant trial.[32]​ Most studies demonstrate equivalent efficacy profiles for methylphenidate and amfetamines preparations, but individual patients may respond to one and not the other due to differences in their mechanism of action as well as differences in formulation (e.g., variable delivery or absorption).[126]​ It is not possible to predict which individuals will respond to which medication.[90]​ Approximately 40% of children with ADHD will respond to treatment with both, and about 40% will respond only to one.[90][127]​​ One large network meta-analysis found that methylphenidate and amfetamines both had moderate-to-large effect sizes when symptomatology was rated by clinicians and teachers. Taking adverse effects into account, the analysis found that the medication with the best benefit-to-risk ratio in children and adolescents with ADHD was methylphenidate.[116]

Adverse effects of stimulants

Amfetamines and methylphenidate are associated with a similar profile of adverse events to each other, including sleep problems, dry mouth, nausea, and decreased appetite.[116][123][124]​​[125][128][129]​​​ One large systematic meta-review found that methylphenidate was associated with a safer risk profile compared to atomoxetine and guanfacine.[128]

Growth suppression is another potential area of concern with long-term stimulant treatment, with evidence suggesting that long-term use may result in a modest reduction in adult height of approximately 1-3 cm.[118][130]​​

The Pediatric Advisory Committee of the FDA has found very rare reports of aggression and psychotic symptoms (specifically visual and tactile hallucinations of insects) in post-marketing safety data. One study of adolescents and young adults (13-25 years old) who started taking prescription stimulants for ADHD found that amfetamines were associated with a greater risk of new-onset psychosis than methylphenidate.[131] A population-based cohort study found no evidence that methylphenidate increases the risk of psychotic events in adolescents and young adults with ADHD, including in those with a history of psychosis.[132]

There are concerns that stimulants may be taken inappropriately for their euphorigenic and performance enhancing effects and may increase the risk of substance use disorders in adolescents, although this concern is disputed by longitudinal research studies which suggest that prescribed stimulants may in fact reduce the risk of substance use disorders in people with ADHD.[133]​ The FDA has noted concerns about non-medical use of prescribed stimulants, particularly with respect to patients sharing their prescribed stimulants with family members and peers. In response, the FDA has mandated updates to product warnings and other information to ensure consistency of prescribing information across all stimulants.[134]​ All healthcare professionals involved in the treatment of ADHD should be alert to the signs of misuse and/or diversion.[111] Prevention of misuse involves offering developmentally appropriate anticipatory guidance and close monitoring, including educational materials and monitoring pill counts.[109]

Another concern is that stimulants may increase the risk of cardiovascular events. Small increases in pulse rate and blood pressure after 24 months of treatment with methylphenidate were noted according to one large European study.[135]​ One study found a slightly increased relative risk of myocardial infarction and arrhythmias in the early period after starting methylphenidate treatment for ADHD in children and young people, mostly in those with a history of congenital heart disease. Other studies have failed to demonstrate an increased risk in adverse cardiac events, stroke and all-cause death with stimulants.[136][137][138]​​​​ The possibility of a small increased risk of serious cardiac adverse events raises the importance of careful risk-benefit analysis, particularly in children with milder symptoms of ADHD.[139] [ Cochrane Clinical Answers logo ] [Evidence C]​

Preparations, dosing, and titration of stimulants

Long-acting stimulant preparations are recommended first-line as they can be taken once a day (eliminating the need to repeat dosing during school hours) can last up to 12 hours or longer, depending on the delivery system.[111][140]​​ They also have a smoother action, with fewer or no rebound symptoms at the end of the day. When titrated to an optimal dose, long-acting formulations have not shown to be a significant cause of sleep problems in treated children.[141]

Doses should be started low (usually the smallest size marketed) and titrated weekly.[90]​ Faster titration is acceptable (e.g., in an urgent situation) but may result in increased adverse effects.[90] There is large individual variability in sensitivity to stimulants, so body weight is only a rough guide of ultimate dose requirement.[90] The dose should be titrated upwards until the elimination of all symptoms or the appearance of unacceptable adverse effects. Often this means pushing the dose to the maximum approved limit.

Various preparations of the same medication can vary in absorption, metabolism, and duration of action. Of particular note, there are differences in long-acting formulations of methylphenidate in terms of dosing frequency, administration with food, amount and timing of the modified-release component, and overall clinical effect. It is important to follow specific dosage recommendations for each formulation, and to use caution if switching from one to another long-acting preparation of methylphenidate. In the UK, prescribers are required to prescribe long-acting formulations of methylphenidate by specifying the brand name or by using the generic drug name and name of the manufacturer.[142] Depending on the country, methylphenidate is available as a solution, an extended-release suspension, chewable tablets, immediate-release and delayed-release tablets/capsules, and as a transdermal patch. Dexmethylphenidate, the d-isomer of methylphenidate, is also available. This variability in preparations can help individualise a regimen (e.g., by changing to a different delivery system or supplementing a long-acting with a shorter-acting preparation). 

Regular contact (e.g., in person or via phone, video call, or email) is recommended during the titration period, including both informal and formal (rating scale) assessments of symptoms and functioning (see Diagnostic approach for information on rating scales).[111]

School-aged children (6-18 years): alternate class of stimulant medication

If treatment with an initial stimulant is ineffective, the best practice in most cases is to try a stimulant from the other class (i.e., to try a methylphenidate-based option if the first drug tried was an amfetamine, or try an amfetamine if the first drug tried was a methylphenidate-based option) before moving to second-line agents.[111] Up to 85% of patients with ADHD will respond if both stimulant classes are tried.[143] There is no evidence-based way to predict which class of stimulants will be effective for a given patient.

Many clinicians will consider referral to a specialist such as a child and adolescent psychiatrist or in the US developmental-behavioural paediatrician (if this has not already taken place) after failure of two stimulant trials and/or if comorbid mental disorder is suspected. Referral to a neurologist is typically indicated if there is intellectual disability, seizure disorder, or a question of a genetic basis. However service models vary according to location of practice, and in some locations (e.g., the UK) specialist referral is recommended following initial suspicion of ADHD.[91]

School-aged children (6-18 years): atomoxetine

Atomoxetine is a noradrenaline (norepinephrine) reuptake inhibitor and a non-stimulant medication indicated for the treatment of ADHD. Unlike the stimulants, atomoxetine has low misuse potential and may be preferred in patients or families with potential for misuse or substance use disorders. Atomoxetine is generally used as a third-line treatment, but it may be an earlier option if there is suggestion of a stimulant-induced tic disorder, or if there is concern over the possibility of substance misuse or use disorders.[144][145]

Studies have shown atomoxetine to be more effective than placebo in reducing ADHD symptoms. It has a moderate effect size which is less than the strong effect size of stimulant medications.[146][147][148][149]​ A head-to-head trial versus methylphenidate suggests that atomoxetine is non-inferior in improving ADHD symptoms.[150] However, long-acting methylphenidate formulations have been associated with a greater response than that observed with atomoxetine.[151] A retrospective chart review suggests that atomoxetine in combination with a stimulant medication may result in better outcomes than atomoxetine alone.[152] Further studies are needed.

In contrast to stimulants that work immediately, the full effect from atomoxetine requires several weeks of treatment. This medication does not exacerbate tics, so can be used as one of a number of options for patients with problematic stimulant-induced tics.[145][153]​​ Regarding safety concerns, atomoxetine has a warning concerning an increase in suicidal thinking in children and adolescents. In controlled studies, the risk was small (only 4 per 1000 cases) and there were no completed suicides.[32] This warning should be discussed with patients and family and the patient monitored for suicidal thinking in the first few months of treatment. In addition, there have been several cases of severe liver damage.[154] While routine monitoring of liver function tests is not recommended, the medication should be discontinued if signs of hepatic disease emerge (e.g., jaundice, dark urine). It is more likely to cause nausea, vomiting, and drowsiness than methylphenidate, according to one meta-analysis.[155]

Atomoxetine can also cause increases in heart rate and blood pressure (BP), and as with stimulants should be used cautiously in patients with cardiovascular disease.[128]​ As with stimulants, routine ECG screening is not recommended.

School-aged children (6-18 years): alpha-2-adrenergic agonists

Treatment with an alpha-2-adrenergic agonist (e.g., guanfacine, clonidine) is an alternative third-line option. They are widely prescribed to treat symptoms of ADHD, and may also have beneficial effects on comorbid aggression, stimulant-induced tics, and stimulant-induced insomnia.[156] They are non-stimulant drugs with low substance misuse/substance use disorder potential. Evidence to support their use for symptoms of ADHD was reviewed in one meta-analysis of 11 studies, which demonstrated a moderate effect on ADHD symptoms.[157]

Guanfacine is an alpha-adrenergic agonist that is often used with ADHD patients who have comorbid tic disorders or who cannot tolerate the stimulant medications or atomoxetine.[145] It is less sedating than the other alpha-adrenergic agonist, clonidine, so is often used during the daytime. The need for multiple daily dosing makes it difficult to coordinate with school; however, the availability of an extended-release formulation may make it more convenient (extended-release guanfacine has been shown to be useful as monotherapy for children and adolescents with ADHD).[158] Studies have shown that treatment with extended-release guanfacine, particularly in combination with a stimulant, is effective in reducing the symptoms of ADHD compared with placebo.[159][160]​ In addition, one double-blind study showed effectiveness of extended-release guanfacine in patients with ADHD and oppositional symptoms.[161]

Two randomised controlled trials (RCTs) demonstrated that extended-release clonidine improved the symptoms of ADHD significantly more than placebo, and that extended-release clonidine was well tolerated.[162][163]

Expert consensus suggests alpha-2-adrenergic agonists are more effective for the hyperactive-impulsive symptoms of ADHD than for the inattentive symptoms.[32]

As these medications are antihypertensives, occasional effects include hypotension, bradycardia, and rebound hypertension.[157] Guanfacine was associated with QT prolongation in one umbrella review of network meta-analyses.[128]​ The physician should elicit cardiovascular history before beginning treatment, monitor BP at the initiation of the medication and during dose adjustments, and gradually adjust doses to avoid BP changes. Other adverse effects of both medications include sedation, dry mouth, and dizziness.[128]

School-aged children (6-18 years): bupropion

If a patient does not respond to stimulants, atomextine, or alpha-2-adrenergic agonists, a specialist clinician should review the diagnosis, and consider comorbid diagnoses such as depression or learning disorders. Further-line treatments which may be considered in secondary care include bupropion.

Bupropion has been shown in several double-blind, placebo-controlled trials to be more effective than placebo and to have a smaller effect size than stimulant medications.[164][165] Because it can lower seizure threshold, bupropion is contraindicated in patients with known seizure disorder. It is often given in divided doses to enhance safety and minimise adverse effects.

School-aged children (6-18 years): psychosocial treatments

Behavioural therapy is the first-line psychosocial treatment of choice.[90][91] It may be delivered within school and/or with parents, but the overarching principle is that it is based on a behaviour modification approach. Liaison with school and college is an important part of behavioural management of ADHD, and the educational provider is a key contributor to the treatment plan.[90][91] 

Behavioural therapy is recommended as an adjunct when pharmacological treatment is used according to international treatment guidelines, and simple behavioural management or parent support programmes may be considered as an initial stand-alone option in primary care for children with mild to moderate impairment, according to UK guidance.[90][91][111]

In the US, the American Academy of Pediatrics recommends that all children and adolescents receiving pharmacological treatment for ADHD should also be offered:[90]

  • Parent training in behavioural management and/or

  • Behavioural classroom interventions

They note that treatments often work best when used together.[90]

The National Institute for Health and Care Excellence (NICE) in the UK recommends that a course of cognitive behavioural therapy (CBT) may be offered to young people with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment, addressing areas such as social skills with peers, problem-solving, self-control, active listening skills, and dealing with and expressing feelings.[91]

Behavioural therapy in conjunction with medication is often particularly beneficial if a patient with ADHD has a less than optimal response to medication, has a comorbid disorder, or experiences family stress.[32][112]

Behavioural therapy typically consists of parent training in communication, positive feedback, effective time-outs, and coordination of a school behavioural plan.[32][112]​ The MTA study was a National Institute of Mental Health study of 579 children with ADHD, which compared the efficacy of stimulant medications, behavioural therapy, and combined stimulants and behavioural therapy over 14, 24, and 36 months. It determined that medications were clearly superior to behavioural treatment alone in all ADHD domains. However, combined medication and behavioural therapy did yield improvement in key areas (including parent and teacher ratings of inattention, parent rating of hyperactivity-impulsivity, parent rating of oppositional/aggressive behaviours, and internalising symptoms of anxiety and depression) at a lower dose of medication. Behavioural therapy either alone or in combination with stimulant medications is the only intervention that led to sustained improvement in parent-reported homework problems.[166]

One systematic review of treatments in adolescents found that psychosocial treatments incorporating behaviour contingency management and motivational strategies in addition to academic, organisational, and social skills training techniques had inconsistent effects on ADHD symptoms; however, they had clear benefit for academic and organisational skills.[167] There is little evidence on whether or not social skills training for children and adolescents with ADHD is effective.[168] [ Cochrane Clinical Answers logo ]

Meta-analysis has shown that integrated medical and behavioural care improves outcomes compared with usual primary care for children and adolescents with disorders including ADHD. The strongest effect was seen with collaborative care models.[169]

School-age children (6-18 years): management of comorbid mental health conditions

Co-existing mental health conditions such as depression and anxiety are common, and identification of comorbidities is important in developing the most appropriate treatment plan. The American Academy of Pediatrics notes that in some cases, the presence of a comorbid condition will alter the treatment of ADHD.[90] Evidence on treatment for children with ADHD and co-existing conditions is limited.

In the first instance, clinicians should determine whether immediate referral or crisis management is required, for example, in the presence of suicide risk or other risk to self or others. Otherwise, the next step is typically to establish which is the most impairing condition, and to manage this condition first, as detailed in specific evidence-based guidance on that particular condition. If the ADHD symptoms are more impairing, there is some evidence to suggest that evidence-based interventions for ADHD may be effective in reducing both symptoms of ADHD and co-existing anxiety or depressive symptoms. If pharmacological treatment for ADHD is required for a child or adolescent with co-existing anxiety or depression, stimulants are usually considered as first-line.[170]​ Behavioural interventions for ADHD may be particularly useful for children with ADHD and psychiatric comorbidities, and there is some evidence that combined behavioural and stimulant medication treatment may have a greater positive effect on depression and anxiety in the presence of coexisting ADHD than behavioural treatment alone.[112][171]​​

In more complex cases when ADHD co-exists with another mental health or developmental disorder an in-depth, interprofessional assessment may be required to assess the relative significance of ADHD versus the coexisting disorder and to identify the most important functional impairments as targets for intervention and treatment. Simultaneous treatment with multiple psychosocial interventions, and sometimes, more than one psychopharmacological agent, may be required.[109]

School-age children (6-18 years): management of co-existing substance use disorder

Identification of suspected or confirmed substance use disorder requires immediate brief intervention and referral to an addiction or mental health specialist. Expert consensus typically states that treatment should address addiction first, before going on to address ADHD.[109][172] Once substance use problems have been stabilised, simultaneous and integrated treatment of ADHD and the substance use disorder using a combination of pharmacotherapy and psychotherapy is recommended for situations where treatment is safe.[173]​​​​

If prescribing medication for ADHD within the context of suspected or confirmed substance misuse, clinicians should select medications with lower liability for misuse. Stimulant drugs may still be considered as first-line options, although preparations with lower liability for misuse, such as extended-release or transdermal formulations, are recommended.[109][172][173] As with any clinical decision, the key is a careful risk:benefit analysis. Clinicians will need to determine whether it is reasonable to initiate or continue stimulant pharmacotherapy, taking into account individual patient factors.​​​​

A number of different amfetamine medications are available with variable half-lives; one example of an amfetamine formulation with lower misuse potential is lisdexamfetamine. Although the FDA includes lisdexamfetamine as a scheduled drug, the misuse potential is extremely low since the active drug is covalently bonded to lysine and only released to its active form by a slow rate-limited process. Similarly, the technology used in some brands of methylphenidate means that the drug is released slowly, and there is minimal risk of misuse or diversion. There is some evidence to suggest that methylphenidate has lower misuse potential compared with amfetamines.[109]

For adolescents with substance use disorder who are prescribed stimulants, close monitoring and anticipatory discussion with the patient and their family is paramount. Monitoring strategies may include pill counts, drug testing, frequent clinical contact and, in locations such as the US, frequent electronic database checks.[173]​ Clinicians may consider arranging for a parent, health professional (e.g., trained school nurse), or other trusted adult to directly observe administration of the medicine, and counsel families on the importance of safely storing and restricting access to controlled medicines.[173]​

Other options to consider are the non-stimulant drugs atomoxetine, guanfacine, or clonidine, although evidence of efficacy is lower.[173]​ Availability of different preparations varies widely according to location of practice, and prescriber knowledge of local treatment availability is required.

There is a theoretical and as-yet quantified risk of combining prescription psychostimulants with substances of misuse.[174]

School-age children (6-18 years): management of co-existing tic disorders

Concerns have been noted that stimulant medications may cause or exacerbate tics, although this concern is not supported by the available evidence.[145][175] If ADHD symptoms are more impairing than tics, standard management for ADHD should be considered. If pharmacological treatment for ADHD is required, stimulants may be selected as first-line even in the presence of co-existing tics, given their superior evidence for efficacy in improving ADHD symptoms compared to non-stimulant medications.[91]​ If tics emerge or increase and are experienced as unacceptable, options include a trial of discontinuation of the stimulant with later rechallenge, addition of an intervention to address tics, for example, comprehensive behavioural intervention for tics (CBIT) or use of a tic-reducing medication such as clonidine or guanfacine, or a change to a non-stimulant ADHD medication such as atomoxetine.[145] Explain the options as above for patients and their parents to consider, but note that some parents and patients may be hesitant to use stimulants in the presence of a co-existing tic disorder despite reassurance, and may instead prefer to start with medication that can improve co-existing conditions, for example, clonidine or guanfacine.[145] Co-prescribing of a non-stimulant in combination with a stimulant may be considered.

Referral to a specialist

In some areas including the UK, referral to a specialist is indicated before pharmacological treatment can be initiated.[91] In the US, a general guide is that referral to a specialist in the treatment of ADHD (e.g., a child psychiatrist, neurologist, or developmental-behavioural paediatrician) should typically be initiated (if this has not already taken place) if two medication trials have failed or for patients in whom comorbid psychiatric disorders are suspected (e.g., depression and ADHD) or who have suspected epilepsy, intellectual disability, or a genetic disorder.[90]

Risk of suicidal ideation

Referral is important if there is suicidal ideation. One large population-based study from Sweden found no evidence for a positive association between the use of drug treatments for ADHD and risk of concomitant suicidal behaviour among patients with ADHD; if anything, the results point to a potential protective effect of drugs for ADHD on suicidal behaviour, particularly for stimulant drugs.[176][177][178]​​ A population-based case series study from Hong Kong found that for patients with ADHD (aged between 6 and 25 years) prescribed methylphenidate, the risk of suicide attempts was highest in the 90 days before treatment was started, suggesting that any link between methylphenidate use and suicidality is not causal.[179] However, studies into the link are ongoing, and caution should be used.

Diet and supplements

There is considerable research and public interest in the role of dietary interventions and their role in neurodevelopmental and psychiatric disorders.[180]​ At present, there is no clear evidence to suggest that dietary modifications or supplements are effective in the management of ADHD.[181][182][183]​​​​​​ Three meta-analyses found evidence of some improvements in clinical symptoms and cognition in children and adolescents with ADHD given omega-3 polyunsaturated fatty acid supplements.[87][88][184]​​​​​​ A meta-analysis of five small double blind studies suggests that restricting synthetic food colouring from children’s diets may be associated with a small reduction in symptoms of ADHD.[185]​ Total fruit and vegetable intake was negatively associated with symptoms of inattention in children with ADHD according to one RCT, with those eating less fruit and vegetable less likely to have severe symptoms of inattention, although the study did not establish causality.[186]​ In adults, there is some evidence of a small association between ADHD symptoms and unhealthy eating habits.[187] There is no evidence that sugar has an effect on behaviour or cognition in children.[188][189]​​ In the absence of clear data on the role of diet and supplements in ADHD, clinicians should continue to offer standard advice on healthy dietary habits in children.[190]

Other nonpharmacological interventions

There is no clear evidence that non-pharmacological interventions (other than behavioural therapy), including meditation-based interventions (e.g., mindfulness and yoga), EEG feedback, and chiropractic care, are effective in the management of ADHD.​​[191][192]

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