Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder, usually first diagnosed in childhood, characterized by inattention, impulsivity, and/or hyperactivity.
One thing to consider is that the current binary diagnosis of either someone having ADHD or not having ADHD does not reflect the actual reality of how attention span works, which is that attentional capacity is on a spectrum.[19]
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by the (1) inattention category and/or (2) hyperactivity and impulsivity category:
At least 6
of the following symptoms have persisted for at least 6
months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
5
symptoms are required.
At least 6
of the following symptoms have persisted for at least 6
months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
5
symptoms are required.
Several inattentive or hyperactive-impulsive symptoms were present prior to age 12
years.
Several inattentive or hyperactive-impulsive symptoms are present in at least 2
settings (e.g. - home, school, work, with friends or relatives, in other activities).
There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder.
CALL FOR FRED
, this can be used to remember the inattention criteria. When the child is impulsive and hyperactive, he or she RUNS FASTT
, this can be used to remember the hyperactivity-impulsivity criteria.[20]
Inattention Criteria
C
- Careless mistakesA
- Attention difficultyL
- Listening problemsL
- Loses thingsF
- Fails to finish what he/she startsO
- Organizational skills lackingR
- Reluctance to do tasks that need sustained mental effortFR
- Forgetful in routine activitiesED
- Easily distractedHyperactivity-Impulsivity Criteria
R
- Runs or is restlessU
- Unable to wait for his or her turnN
- Not able to play quietlyS
- Slow? – Oh no! He's on the go!F
- Fidgets with hands or feetA
- Answers blurted outS
- Staying seated is difficultT
- Talks excessivelyT
- Tends to interruptA review of just the DSM criteria is not enough to justify a diagnosis of ADHD! A formal psychiatric interview, plus a detailed review of the following history also needs to occur:[21]
Name | Rater | Description | Download |
---|---|---|---|
ADHD Checklist | Clinician/Patient | The ADHD Checklist is a list of the 9 DSM items of attention and the 9 DSM items of hyperactivity/impulsivity. The checklist can also be completed to identify ADHD in adults in childhood, or completed by a collateral informant as well as the patient. | Download |
SNAP-IV 26 | Teacher/Parent | The SNAP-IV is a 26-item rating scale, ranging from a 0 to 3 rating scale. Sub scale scores on the SNAP-IV are calculated by summing the scores on the subset and dividing by the number of items in the subset. | Download |
Adult ADHD Self-Report Scale | Patient | The Adult ADHD Self-Report Symptom Checklist is an 18-item scale that contains the 18 DSM-IV-TR ADHD criteria. | Download |
Conners’ Rating Scale-Revised | Clinician/Patient | Scale administered to parents and teachers of children and adolescents age 6-18. Self-report, age 8-18 | Link |
Not every inattentive or disruptive youth has ADHD! Even those who do have ADHD are likely to have at least one other comorbid condition. A youth may be inattentive or act out because of normal developmental variation, problems related to sleep (e.g. - obstructive sleep apnea), diet, impaired hearing or vision, learning disabilities, anxiety disorders, depression, and/or substances use. Always consider a psychoeducational assessment, including both cognitive and academic testing, to assess for learning problems.
Psychoeducation involves discussing the impact of ADHD on day-to-day functioning, treatment options, and strategies for optimizing function. Psychoeducation can help empower patients and families by providing information on ADHD.[56] It has been found to increase knowledge, enhance treatment adherence, and improve attitudes and intended behaviours towards the person with ADHD.[57] Psychoeducation typically involves:
Planning and organization skills may be suboptimal in individuals with ADHD.[58] Behavioural and sychosocial interventions in various environments (home, social situations, extracurricular activities, workplace, and academic) help improve functioning in these unstructured environments. Additionally, it is important to note that psychosocial treatment is the first line treatment for preschoolers. Even for non-high schoolers, behavioural interventions have strong evidence for throughout the lifespan.[59]
Instructional | • Get eye and/or gentle physical contact before giving one or two clear instructions. • Get the person to repeat the instructions before proceeding. |
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Behavioural | • Use a positive approach and calm tone of voice. Avoid yelling and arguing. • Encourage calming techniques to de-escalate conflict. Example: Teach “stop and think”. Help them put on their brakes by taking deep breaths. • Use praise, “catch them being good” (doing chores, playing nicely). • Set clear attainable goals and limits (specific homework routine, bedtime routine, chores, etc.) and tie them to earning privileges, special outings, etc. • Use positive incentives and natural consequences; “When you…(do homework ) …then you …(may go play )”; if…then. • Use empathy statements such as “I understand” / “however” can be useful. • Recommend that adults model emotional self-regulation and encourage a balanced lifestyle (nutritious meal planning, exercise, hobbies and sleep hygiene). • Schedule family and partner time. • Keep choices limited to two or three options. • Make rewards meaningful and timed in close proximity to the desired behavior. |
Enivronmental | • Implement structure and routines. • Parents/partners must be united, consistent, firm and fair. Follow through with agreed consequences. • Help them prioritize instead of procrastinating. • Post visual reminders (rules, lists, reminders, sticky notes, calendars) in prominent locations, using different colors to accentuate/prioritize. • Use timers/apps for deadlines (routines, homework, chores, paying bills, limiting electronics). • Keep labeled, different coloured folders or containers in prominent locations for items (keys, electronics, household items). • Find work area best suitable to individual, e.g. dining room table, quiet areas. • Chunk tasks (divide larger tasks into smaller ones) and assign specific deadlines to each step. • Allow planned frequent movement breaks during prolonged tasks. • Allow white noise, a fan or background music during homework, work or at bedtime. |
Workplace | • Identify accommodation needs. • Request accommodations supports (Suggest using the CADDRA Template letter and adapting to your patient’s situation). • Suggest regular and frequent meetings with manager and support collaborative approach. • Set goals, learn to prioritize, review progress on a regular basis. • Identify time management techniques that work for individual, i.e. using a planner, apps). • Declutter and create work friendly environment. • Use organizational Apps (i.e. Evernote, Omnifocus, Todoist). • Explore productivity Websites (e.g. 43folders.com, zenhabits.net). • Get assistance from an ADHD Coach. • Review workplace strategies and accommodations at www.caddac.ca. |
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Instructional | • Give clear and precise directions. • Get the student’s attention before providing instructions. • Check the student’s understanding by having the student repeat instructions and provide clarification as needed. • Use direct requests – “when-then”. |
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Behavioural | • Provide immediate and frequent feedback. • Provide students with positive feedback and encouragement more frequently than negative feedback. • Provide students with specific feedback – “thank you for putting your hand up to ask a question”. • Use visual cues in the classroom or on the desk for transitions. • Use visual prompts/pictures or lists for task initiation and task completion. • Chunk and break down steps to initiate tasks. • Reduce the amount of work required to show knowledge i.e. rather than asking a child to do 10 addition questions, requiring them to do 5. • Providing clear expectations and structure in the classroom. • Allow for acceptable opportunities for movement: “walking passes”. |
Environmental | • Preferential seating away from distractions. • Proximity to the teacher. • A quiet place in the classroom for calming down or working. • Being seated beside a “more attentive” buddy. • Increase change and introduce novelty. |
Academic | • Actively engage the student by providing work at the appropriate academic level. • Allow extended time (1.5 x) to complete quizzes, tests and exams. • Permit student to write quizzes, tests and exams in a quiet room. • Allow ear-plugs/ head-phones to help reduce external noises during tests • Provide a scribe or note taker or access to assistive technology. • Assign homework as necessary but monitor quantity. |
Executive Function | • Find a tutor or academic coach. • Seek a structured classroom. • Establish a routine. • Keep an assignment notebook. • Develop an organization notebook. • Organize what needs to be taken to school the night before. • Monitor and prompt to get started on tasks. • Teach awareness of time; time management. • Use graphic organizer for long-term projects. |
Post-secondary | • Encouraging students to contact the Accessibility/Disability Centres. • Allow extended time for assignments, especially if numerous assignments are all due at the same time. • Allow extended time on tests/exams. • Organizational apps to keep notes, lists, ideas and more e.g. Evernote and Simplenote, Mind Manager. • Technological support to better organize thinking, taking notes, writing, e.g. Livescribe, AudioNote, One Note, SoundNote, Audiotorium and Screen Record • Concept Mapping can be achieved on the computer by using graphic organizers (e.g., Inspiration, Writers Companion, Draft Builder). • Access to preferential seating in lectures (close to the lecturer, away from visual or auditory distractions such as cycling heating/cooling units). • Access to a scribe or note taker to take notes for those courses where it is necessary to focus on the lecture rather than switching attention between the lecture to ensure lecture notes are adequate and thorough enough to review for tests/exams. • Obtaining advance copies of lecture notes, overheads, etc. so that the student can focus on the lecture rather than read what's on the board, take notes, and listen all at the same time. • Use videotape lectures if granted permission and review them later to reinforce class work. • Devices such as a tablet as well as apps that help with writing such as planning (e.g., Inspiration); drafting (e.g., Dragon Dictation, iPad Dictation); and note-taking (e.g., Notability). • Work with accessibility/disability staff to review and chunk assignments, check details, assist with time management and due dates and review progress. • Access to ‘prompt’ sheets/memory aids with outline of steps, formulas etc. • Coaching to identify strengths, negotiate problems, and work on specific goals. |
Many types of standardized, or structured behavioural interventions have been investigated, including:
Stimulants are considered the main treatment in ADHD in adolescents and adults, and there are two main classes of medications: amphetamines and methylphenidate (both classes are available in short, intermediary and long-acting preparations). The average response rate to medications is about 70%.[63] The overall response rate in the short-term (i.e. - 12 months) for stimulants is about 90%. Around 40% of individuals will have equal response to methylphenidate and amphetamine, and another 20% each will respond to only one class of medications. On a population level, there is no difference in the efficacy and tolerability between amphetamines and methylphenidate, but individuals may have a better response on one class compared to another.[64] While there is considerable data support the short-term benefits of ADHD treatment, there is little evidence that it improves long-term functional outcomes.[65][66][67] The general ADHD treatment principles are:[68]
Tradename | Active ingredient | Formulations | Starting Dose | Titration (q7 days) | Max Dose (6-12 years) (CADDRA*) | Max Dose (13-17 years) (CADDRA*) | Max Dose (18+) (CADDRA*) |
---|---|---|---|---|---|---|---|
Adderall XR | Amphetamine mixed salts | 5, 10, 15, 20, 25, 30 mg cap | 5-10 mg q AM (adults can start at 10 mg) | ↑ 5 mg | 30 mg (30 mg) | 30 mg (50 mg) | 30 mg (50 mg) |
Biphentin | Methylphenidate | 10, 15, 20, 30, 40, 50, 60, 80 mg cap | 10-20 mg q AM | ↑ 5-10 mg | 60 mg (60 mg) | 60 mg (80 mg) | 80 mg (80 mg) |
Concerta | Methylphenidate | 18, 27, 36, 54 mg tab | 18 mg q AM | ↑ 9-18 mg | 54 mg (72 mg) | 54 mg (90 mg) | 72 mg (108 mg) |
Vyvanse | Lisdexamfetamine | 10, 20, 30, 40, 50, 60, 70 mg cap | 20-30 mg q AM | ↑ 10 mg | 60 mg (60 mg) | 60 mg (70 mg) | 60 mg (70 mg) |
Tradename | Active ingredient | Formulations | Starting Dose | Titration (q7 days) | Max Dose (6-12 years) (CADDRA*) | Max Dose (13-17 years) (CADDRA*) | Max Dose (18+) (CADDRA*) |
---|---|---|---|---|---|---|---|
Dexedrine | Dextro-amphetamine | 5 mg tab | 2.5-5 mg BID | ↑ 2.5-5 mg | 40 mg (20 mg) | 40 mg (30 mg) | 40 mg (50 mg) |
Dexedrine Spansule | Dextro-amphetamine | 10, 15 mg cap | 10mg q AM | ↑ 2.5-5 mg | 40 mg (30 mg) | 40 mg (30 mg) | 40 mg (80 mg) |
Ritalin | Methylphenidate | 10, 20 mg tab (5 mg generic only) | 5 mg BID to TID | ↑ 5 mg | 60 mg (60 mg) | 60 mg (60 mg) | 60 mg (100 mg) |
Ritalin SR | Methylphenidate | 20 mg tab | 20 mg q AM | ↑ 20 mg | 60 mg (60 mg) | 60 mg (80 mg) | 60 mg (100 mg) |
Tradename | Active ingredient | Formulations | Starting Dose | Titration (q7 days) | Max Dose (6-12 years) (CADDRA*) | Max Dose (13-17 years) (CADDRA*) | Max Dose (18+) (CADDRA*) |
---|---|---|---|---|---|---|---|
Intuniv XR | Guanfacine | 1, 2, 3, 4 mg tab | 1 mg | ↑ 1 mg q 7-14 days | 4 mg (4 mg) | 7 mg for monotherapy and 4 mg for adjunctive therapy | Not used in adults |
Strattera | Atomoxetine | 10, 18, 25, 40, 60, 80, 100 mg cap | • Children (6-12 years): 0.5 mg/kg/day • Adolescents (3-17 years): 0.5 mg/kg/day • Adults (18+): 40 mg daily | • Children and Adolescents: ↑ q 7-14 days; first to 0.8 mg/kg/day, then 1.2 mg/kg/day • Adults: ↑ q 7-14 days; to 60 mg then 80 mg/day | Lesser of 1.4 mg/kg/day or 60 mg/day | Lesser of 1.4 mg/kg/day or 100 mg/day | Lesser of 1.4 mg/kg/day or 100 mg/day |
Having an approach to prescribing can help the clinician assess whether a medication is working, and provides a systematic approach to monitoring prescribing:
Class | Contraindications | Precautions | Monitoring during Treatment |
---|---|---|---|
Any ADHD medication | Known hypersensitivity or allergy to the products | • Cardiac disease • Bipolar disorder • Psychosis • Pregnancy and lactation | • Height and weight in children • New mood, anxiety, substance use disorder, psychotic or manic symptoms • Suicidal behaviour or ideation‡ • Aggressive behaviour (new or worsening) • Sleep, appetite • Irritability or mood swings |
Stimulants | • Treatment with MAOI or RIMA and for up to 14 days after discontinuation. • Glaucoma (narrow angle) • Untreated hyperthyroidism • Moderate to severe hypertension • Pheochromocytoma • Symptomatic cardiovascular disease • History of mania or psychosis | • History of substance abuse • Anxiety (generally speaking, treatment outweighs risks) • Renal impairment • Tic disorders • Epilepsy • Peripheral vasculopathy including Raynaud’s Phenomenon | • BP, HR (may increase) • Palpitations • Priapism† • Growth retardation • Peripheral vasculopathy including Raynaud’s Phenomenon • Insomnia or sleep disturbance |
Atomoxetine | • Treatment with MAOI or RIMA and for up to 14 days after discontinuation. • Narrow angle glaucoma • Uncontrolled hyperthyroidism • Pheochromocytoma • Moderate to severe hypertension • Symptomatic cardiovascular disease • Severe cardiovascular disorders • Advanced arteriosclerosis | • Asthma* • CYP2D6 poor metabolizers • Peripheral vasculopathy including Raynaud’s Phenomenon | • Priapism† and urinary retention • Signs / symptoms of liver injury • Growth retardation • Peripheral vasculopathy including Raynaud’s Phenomenon |
Alpha-2 Agonists (e.g. - guanfacine, clonidine) | Inability for parents or patients to ensure regular daily dosage (due to the risk of rebound hypertension when stopped abruptly) | • Hepatic impairment • Kidney impairment | • Somnolence and sedation • BP, risk of hypotension • Bradycardia, syncope • Elevated BP and HR upon abrupt discontinuation • QTc interval (to be monitored if underlying conditions or other medication increase the risk of prolonged QTc interval) |
Stimulant | Atomoxetine | Alpha-2 Agonist | |
---|---|---|---|
Hypotension (BP ↓) and Bradycardia (HR ↓) | - | - | ✓ |
Hypertension (BP ↑ 5 mmHg) and Tachycardia (HR ↑ 10bpm) | ✓ | ✓ | When stopped suddenly (rebound hypertension) |
Appetite supression | ✓ | ✓ | Low incidence |
Constipation/diarrhea | ✓ | ✓ | ✓ |
Dry mouth | ✓ | ✓ | ✓ |
GI upset | ✓ | ✓ | Upper abdominal pain |
Nausea/vomitting | ✓ | ✓ | ✓ |
Anxiety | ✓ | ✓ | Low incidence |
Dizziness | ✓ | - | - |
Dysphoria/irritability | ✓ | ✓ | Uncommon |
Headache | ✓ | ✓ | Yes |
Initial insomnia | ✓ | ✓ | Low incidence |
Rebound effect | ✓ | - | - |
Tics | ✓ | Uncommon | - |
Weight loss | ✓ | ✓ | - |
Sexual dysfunction | Uncommon | ✓ | - |
Skin reactions | ✓ | ✓ | Low incidence |
There remains a paradox and debate about why individuals on long-term treatment on stimulants did not fare better than those who did not. Furthermore, the NIMH MTA website and MTA FAQ also acknowledges the modest benefits of long-term treatment. Other population studies have also suggested this finding as well.[78] Finally, at the 16-year follow up of the MTA study, ongoing medication was not associated with reduction of symptom severity, and additionally was associated with height loss of approximately 1-inch.[79]