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| ====== Attention-Deficit/Hyperactivity Disorder (ADHD) ====== | ====== Attention-Deficit/Hyperactivity Disorder (ADHD) ====== | ||
| + | {{INLINETOC}} | ||
| ===== Primer ===== | ===== Primer ===== | ||
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| == Epidemiology == | == Epidemiology == | ||
| - | The general prevalence of ADHD is estimated at between 5-9% for children and adolescents,[([[https://www.ncbi.nlm.nih.gov/pubmed/25733754|Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.]])] 3-5% for adults, and a world-wide prevalence of 5%.[([[https://www.ncbi.nlm.nih.gov/pubmed/17541055|Polanczyk, G., De Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American journal of psychiatry, 164(6), 942-948.]])] 70% of school-aged children with ADHD have at least one other co-morbid psychiatric disorder such as [[anxiety:gad|generalized anxiety disorder]], [[child:disruptive-impulsive:odd|oppositional defiant disorder]], [[ocd:1-ocd|obsessive-compulsive disorder]], [[child:motor:tic-disorders|tic disorders]] or [[mood:1-depression:home|depression]]. | + | * The general prevalence of ADHD is estimated at between 5-9% (average 7%) for children and adolescents,[([[https://www.ncbi.nlm.nih.gov/pubmed/25733754|Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.]])] 3-5% for adults, and a world-wide prevalence of 5%.[([[https://www.ncbi.nlm.nih.gov/pubmed/17541055|Polanczyk, G., De Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American journal of psychiatry, 164(6), 942-948.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4817588/|Polanczyk, Guilherme V., et al. "ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis." International journal of epidemiology 43.2 (2014): 434-442.]])] |
| + | == Prognosis == | ||
| + | * Although ADHD is classically considered to be a life-long condition, between one-third to one-half of individuals' symptoms will remit by adulthood.[([[https://pubmed.ncbi.nlm.nih.gov/25612927/|Karam, R. G., Breda, V., Picon, F. A., Rovaris, D. L., Victor, M. M., Salgado, C. A. I., ... & Bau, C. H. D. (2015). Persistence and remission of ADHD during adulthood: a 7-year clinical follow-up study. Psychological medicine, 45(10), 2045.]])][([[https://pubmed.ncbi.nlm.nih.gov/30194962/|Sudre, G., Mangalmurti, A., & Shaw, P. (2018). Growing out of attention deficit hyperactivity disorder: Insights from the ‘remitted’brain. Neuroscience & Biobehavioral Reviews, 94, 198-209.]])] | ||
| + | * Childhood ADHD has been found to be associated with worse educational (lower grades, truancy), occupational economic, social, and health related outcomes.[([[https://pubmed.ncbi.nlm.nih.gov/23070149/|Klein, R. G., Mannuzza, S., Olazagasti, M. A. R., Roizen, E., Hutchison, J. A., Lashua, E. C., & Castellanos, F. X. (2012). Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Archives of general psychiatry, 69(12), 1295-1303.]])] | ||
| + | * ADHD in children is linked to a 2 times greater risk for accidental injuries of all types.[([[https://pubmed.ncbi.nlm.nih.gov/28554188/|Amiri, S., Sadeghi-Bazargani, H., Nazari, S., Ranjbar, F., & Abdi, S. (2017). Attention deficit/hyperactivity disorder and risk of injuries: a systematic review and meta-analysis. Journal of injury and violence research, 9(2), 95. | ||
| + | ]])] | ||
| + | * Adolescents with ADHD have a higher risk of earlier substance use, and greater difficulty with substance use.[([[https://pubmed.ncbi.nlm.nih.gov/28150391/|Steinberg, L., Icenogle, G., Shulman, E. P., Breiner, K., Chein, J., Bacchini, D., ... & Fanti, K. A. (2018). Around the world, adolescence is a time of heightened sensation seeking and immature self‐regulation. Developmental science, 21(2), e12532.]])] | ||
| + | * ADHD symptoms can negatively impact the ability to drive safely in both adolescents and adults.[([[https://pubmed.ncbi.nlm.nih.gov/8337019/|Barkley, R. A., Guevremont, D. C., Anastopoulos, A. D., DuPaul, G. J., & Shelton, T. L. (1993). Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: a 3-to 5-year follow-up survey. Pediatrics, 92(2), 212-218.]])] | ||
| + | * ADHD is associated with deficits in executive function, including: inhibitory control, working memory, and effortful attention.[([[https://pubmed.ncbi.nlm.nih.gov/17318413/|Stefanatos, G. A., & Baron, I. S. (2007). Attention-deficit/hyperactivity disorder: A neuropsychological perspective towards DSM-V. Neuropsychology review, 17(1), 5-38.]])] | ||
| + | |||
| + | == Comorbidity == | ||
| + | * Between 50 to 90% of school-aged children with ADHD have at least one other comorbid psychiatric disorder, most commonly: [[anxiety:home|anxiety disorders]], [[child:disruptive-impulsive:odd|oppositional defiant disorder]], and language disorders. | ||
| + | * In adolescents, [[child:motor:tic-disorders|tic disorders]] (50-90%) are highly comorbid. | ||
| + | * Anxiety disorders, [[ocd:1-ocd|obsessive-compulsive disorder]] are also comorbid. | ||
| + | * 85% of adults with ADHD meet criteria for a comorbid mental disorder,[([[https://pubmed.ncbi.nlm.nih.gov/19835674/|Cumyn, L., French, L., & Hechtman, L. (2009). Comorbidity in adults with attention-deficit hyperactivity disorder. The Canadian Journal of Psychiatry, 54(10), 673-683.]])] most commonly: mood disorders (both [[mood:1-depression:home|depression]] and [[bipolar:bipolar-i|bipolar disorder]]), and [[addictions:home|substance use disorders]].[([[https://pubmed.ncbi.nlm.nih.gov/16585449/|Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., ... & Spencer, T. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of psychiatry, 163(4), 716-723.]])] | ||
| + | |||
| + | == Risk Factors == | ||
| + | * The heritability of ADHD is about 76% (based on monozygotic twin studies).[([[https://pubmed.ncbi.nlm.nih.gov/15950004/|Faraone, S. V., Perlis, R. H., Doyle, A. E., Smoller, J. W., Goralnick, J. J., Holmgren, M. A., & Sklar, P. (2005). Molecular genetics of attention-deficit/hyperactivity disorder. Biological psychiatry, 57(11), 1313-1323.]])] | ||
| + | * Parents with ADHD have a >50% chance of having a child with ADHD. | ||
| + | * Close to 25% of children with ADHD have parents who meet the formal diagnostic criteria for ADHD. | ||
| + | * First-degree relatives of diagnosed ADHD individuals have a 30 to 40% chance. | ||
| + | * Genes implicated in ADHD include DAT1, DRD4, DRD5, DBH, 5-HTT, HTR1B, and SNAP-25.[([[https://pubmed.ncbi.nlm.nih.gov/15950004/|Faraone, S. V., Perlis, R. H., Doyle, A. E., Smoller, J. W., Goralnick, J. J., Holmgren, M. A., & Sklar, P. (2005). Molecular genetics of attention-deficit/hyperactivity disorder. Biological psychiatry, 57(11), 1313-1323.]])] | ||
| + | * However, due to increasing rates of ADHD diagnoses, non-genetic factors are equally as important and explain the reasons behind rising diagnoses.[([[https://pubmed.ncbi.nlm.nih.gov/30275319/|Christakis, D. A., Ramirez, J. S. B., Ferguson, S. M., Ravinder, S., & Ramirez, J. M. (2018). How early media exposure may affect cognitive function: A review of results from observations in humans and experiments in mice. Proceedings of the National Academy of Sciences, 115(40), 9851-9858.]])] | ||
| + | * Non-genetic risk factors include perinatal stress, low birth weight, traumatic brain injury, maternal smoking during pregnancy, severe early deprivation, and frequent digital media use.[([[https://pubmed.ncbi.nlm.nih.gov/30027248/|Ra, C. K., Cho, J., Stone, M. D., De La Cerda, J., Goldenson, N. I., Moroney, E., ... & Leventhal, A. M. (2018). Association of digital media use with subsequent symptoms of attention-deficit/hyperactivity disorder among adolescents. Jama, 320(3), 255-263.]])][([[https://pubmed.ncbi.nlm.nih.gov/24999762/|Nikkelen, S. W., Valkenburg, P. M., Huizinga, M., & Bushman, B. J. (2014). Media use and ADHD-related behaviors in children and adolescents: A meta-analysis. Developmental Psychology, 50(9), 2228.]])] | ||
| + | * The influence of later birthdate on ADHD diagnoses has also been investigated, suggesting that children may be diagnosed due to their relative age differences within their peer group at a certain grade level.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933294/|Elder, T. E. (2010). The importance of relative standards in ADHD diagnoses: evidence based on exact birth dates. Journal of health economics, 29(5), 641-656.]])] | ||
| + | ===== DSM-5 Diagnostic Criteria ===== | ||
| + | ==== Diagnostic Construct ==== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://www.npr.org/sections/ed/2016/01/04/459990844/were-thinking-about-adhd-all-wrong-says-a-top-pediatrician|NPR: We're Thinking About ADHD All Wrong, Says A Top Pediatrician]]** | ||
| + | </alert> | ||
| + | |||
| + | 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//.[([[https://pubmed.ncbi.nlm.nih.gov/26746874/|Christakis, D. A. (2016). Rethinking attention-deficit/hyperactivity disorder. JAMA pediatrics, 170(2), 109-110.]])] | ||
| - | ===== Diagnostic Criteria ===== | ||
| == Criterion A == | == Criterion A == | ||
| 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**: | 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**: | ||
| Line 45: | Line 76: | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| - | <WRAP group> | ||
| - | <WRAP quarter column> | ||
| == Criterion B == | == Criterion B == | ||
| Several inattentive or hyperactive-impulsive symptoms were present prior to ''age 12'' years. | Several inattentive or hyperactive-impulsive symptoms were present prior to ''age 12'' years. | ||
| - | </WRAP> | + | |
| - | <WRAP quarter column> | + | |
| == Criterion C == | == Criterion C == | ||
| 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). | 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). | ||
| - | </WRAP> | + | |
| - | <WRAP quarter column> | + | |
| == Criterion D == | == Criterion D == | ||
| There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. | There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. | ||
| - | </WRAP> | + | |
| - | <WRAP quarter column> | + | |
| == Criterion E == | == Criterion E == | ||
| - | The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder. | + | The symptoms do not occur exclusively during the course of [[psychosis:schizophrenia-scz|schizophrenia]] or another [[psychosis:home|psychotic disorder]] and are not better explained by another mental disorder. |
| - | </WRAP> | + | |
| - | </WRAP> | + | |
| <callout icon="fa fa-lightbulb-o" type="success" title="Mnemonic"> | <callout icon="fa fa-lightbulb-o" type="success" title="Mnemonic"> | ||
| Line 93: | Line 117: | ||
| </WRAP> | </WRAP> | ||
| </callout> | </callout> | ||
| + | |||
| + | ===== Assessment and Diagnosis ===== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://pubmed.ncbi.nlm.nih.gov/33949916/|Sibley, M. H. (2021). Empirically-informed guidelines for first-time adult ADHD diagnosis. Journal of Clinical and Experimental Neuropsychology, 1-12.]]** | ||
| + | </alert> | ||
| + | |||
| + | A review of just the DSM criteria is not enough to justify a diagnosis of ADHD! A [[teaching:1-psych-interview|formal psychiatric interview]], plus a detailed review of the following history also needs to occur:[([[https://www.caddra.ca/download-guidelines/|Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018]])] | ||
| + | * Medical history | ||
| + | * Rule out any medical issues that may mimic or aggravate symptoms of ADHD | ||
| + | * Nutrition and lifestyle | ||
| + | * [[sleep:home|Sleep]] | ||
| + | * [[teaching:exercise-prescription|Exercise]] | ||
| + | * [[teaching:effect-of-technology-on-mental-health|Screentime]] | ||
| + | * High-risk activities ([[addictions:home|substance use]]) | ||
| + | * Sexual activity | ||
| + | * Accidents (e.g. - concussions, [[cl:tbi|traumatic brain injuries]]) | ||
| + | * Neurological history (e.g. - [[neurology:approach-seizures|seizures]], in particular absence seizures) | ||
| + | * Complete childhood developmental history (a parent, a teacher, or a close family member who knows the individual’s early history may be helpful for collateral) | ||
| + | * **Having an objective third party to provide this history is critical, as the accuracy of self-recall of ADHD symptoms in childhood is not accurate!**[([[https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.159.11.1882|Mannuzza, S., Klein, R. G., Klein, D. F., Bessler, A., & Shrout, P. (2002). Accuracy of adult recall of childhood attention deficit hyperactivity disorder. American Journal of Psychiatry, 159(11), 1882-1888.]])] | ||
| + | * Perinatal history (birth weight, complications, maternal alcohol and tobacco usage during pregnancy) | ||
| + | * Developmental milestones | ||
| + | * Intellectual disability, [[child:learning:home|learning disorders]] | ||
| + | * [[child:learning:psychoeducational-assessment|Psychoeducational assessments]], report cards | ||
| + | * Impact of symptoms on learning, socialization and independent functioning | ||
| + | * Temperament | ||
| + | * Symptoms of ADHD prior to the age of 12 | ||
| + | * Presence of any life events that were of emotional concern in childhood (e.g. - abuse, bullying, divorce, loss, deaths, attachment issues) | ||
| ===== Overdiagnosis ===== | ===== Overdiagnosis ===== | ||
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[teaching:advanced:cognitive-and-diagnostic-errors-overdiagnosis|]]**</alert> | + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> |
| + | See also: **[[https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2778451|Kazda L., et al. Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review. JAMA Netw Open. 2021;4(4):e215335.]]** | ||
| + | </alert> | ||
| + | |||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See also: **[[teaching:cognitive-bias-misdiagnosis-overdiagnosis]]** | ||
| + | </alert> | ||
| <WRAP group> | <WRAP group> | ||
| <WRAP half column> | <WRAP half column> | ||
| - | **ADHD is likely overdiagnosed.**[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500182/|Paris, Joel, Venkat Bhat, and Brett Thombs. Prevalence rates and prescriptions have increased five-fold in the past decade.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/28363250|Zhu, Y., Liu, W., Li, Y., Wang, X., & Winterstein, A. G. (2018). Prevalence of ADHD in publicly insured adults. Journal of attention disorders, 22(2), 182-190.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2993524/|Gualtieri, C. T., & Johnson, L. G. (2005). ADHD: Is objective diagnosis possible?. Psychiatry (Edgmont), 2(11), 44.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/26973148|Chen, Mu-Hong, et al. "Influence of relative age on diagnosis and treatment of attention-deficit hyperactivity disorder in Taiwanese children." The Journal of pediatrics 172 (2016): 162-167.]])][([[https://www.nytimes.com/2016/08/28/books/review/adhd-nation-alan-schwarz.html|New York Times: Overselling A.D.H.D.: A New Book Exposes Big Pharma’s Role]])] It is important to be aware of diagnostic creep and overdiagnosis! True ADHD is a debilitating condition that presents largely in childhood and absolutely should be treated. However, we are likely in a culture of overdiagnosis right now, especially with the ease of prescribing stimulants and short assessments in primary care settings. A short or incomplete assessment means a thorough differential diagnosis has not been considered! Since individuals both with and without ADHD can experience improved attention and decreased restlessness while taking stimulants, //medication response alone is not a basis for diagnosing the disorder//.[([[https://www.ncbi.nlm.nih.gov/pubmed/27690551|McGough, J. J. (2016). Treatment controversies in adult ADHD. American Journal of Psychiatry, 173(10), 960-966.]])] However, this is often a common diagnostic fallacy that many clinicians make. | + | * **ADHD is likely overdiagnosed.**[([[https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2778451|Kazda L., et al. Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review. JAMA Netw Open. 2021;4(4):e215335.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5240230/|Merten, E. C., Cwik, J. C., Margraf, J., & Schneider, S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and adolescent psychiatry and mental health, 11(1), 1-11.]])][([[https://pubmed.ncbi.nlm.nih.gov/29432029/|Fresson, M., Meulemans, T., Dardenne, B., & Geurten, M. (2019). Overdiagnosis of ADHD in boys: Stereotype impact on neuropsychological assessment. Applied Neuropsychology: Child, 8(3), 231-245.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500182/|Paris, J., Bhat, V., & Thombs, B. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed?. The Canadian Journal of Psychiatry, 60(7), 324-328.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/28363250|Zhu, Y., Liu, W., Li, Y., Wang, X., & Winterstein, A. G. (2018). Prevalence of ADHD in publicly insured adults. Journal of attention disorders, 22(2), 182-190.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2993524/|Gualtieri, C. T., & Johnson, L. G. (2005). ADHD: Is objective diagnosis possible?. Psychiatry (Edgmont), 2(11), 44.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/26973148|Chen, Mu-Hong, et al. "Influence of relative age on diagnosis and treatment of attention-deficit hyperactivity disorder in Taiwanese children." The Journal of pediatrics 172 (2016): 162-167.]])][([[https://www.nytimes.com/2016/08/28/books/review/adhd-nation-alan-schwarz.html|New York Times: Overselling A.D.H.D.: A New Book Exposes Big Pharma’s Role]])] |
| + | * It is important to be aware of diagnostic creep and overdiagnosis! True ADHD is a debilitating condition that presents largely in childhood and absolutely should be treated. | ||
| + | * However, we are likely in a culture of overdiagnosis right now, especially with the ease of prescribing stimulants and short assessments in primary care settings. A short or incomplete assessment means a thorough differential diagnosis has not been considered. | ||
| + | * **Since individuals both with and without ADHD can experience improved attention and decreased restlessness while taking stimulants, //medication response alone is not and cannot be the basis for diagnosing the disorder//.**[([[https://www.ncbi.nlm.nih.gov/pubmed/27690551|McGough, J. J. (2016). Treatment controversies in adult ADHD. American Journal of Psychiatry, 173(10), 960-966.]])][([[https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC4125626/|del Campo, N., Fryer, T. D., Hong, Y. T., Smith, R., Brichard, L., Acosta-Cabronero, J., ... & Müller, U. (2013). A positron emission tomography study of nigro-striatal dopaminergic mechanisms underlying attention: implications for ADHD and its treatment. Brain, 136(11), 3252-3270.]])][([[https://www.caddra.ca/download-guidelines/|Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018]])] | ||
| + | * However, this is often a common diagnostic fallacy that most clinicians make. | ||
| + | |||
| + | * It is also important to note that the increase in ADHD diagnoses is multifactorial. | ||
| + | * Factors such as greater awareness of mental health, ADHD itself, and its treatments are contributors. | ||
| + | * Social factors, cultural factors, and the [[teaching:pharmaceutical-industry-influence|influence of pharmaceutical marketing]] also plays a role. | ||
| + | * Finally, insufficient diagnostic training (e.g. - diagnosis in primary care without a detailed psychiatric and developmental history assessment) and lack of resources devoted to non-pharmacological management of childhood behavioural problems may further compound the issue. | ||
| </WRAP> | </WRAP> | ||
| <WRAP half column> | <WRAP half column> | ||
| - | <callout title="Father of ADHD on Current Diagnosis and Treatment of the Condition">"The numbers make it look like an epidemic. Well, it’s not. It’s preposterous ... This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels." | + | <callout title="Father of Modern Conceptualization of ADHD on Current Diagnosis and Treatment of the Condition"> |
| - | \\ \\ | + | //"The numbers make it look like an epidemic. Well, it’s not. It’s preposterous ... This is a concoction to justify the giving out of medication at unprecedented and unjustifiable levels." |
| - | -- Dr. Keith Conners[([[https://www.bmj.com/content/358/bmj.j2253|Frances, A., & Carroll, B. J. (2017). Keith Conners. BMJ: British Medical Journal (Online), 358.]])], child psychologist and father of the modern conceptualization of ADHD. [[https://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html|New York Times: The Selling of Attention Deficit Disorder]] | + | //\\ \\ |
| + | -- [[https://www.bmj.com/content/358/bmj.j2253|Dr. Keith Conners]],[([[https://www.bmj.com/content/358/bmj.j2253|Frances, A., & Carroll, B. J. (2017). Keith Conners. BMJ: British Medical Journal (Online), 358.]])] child psychologist and father of the modern conceptualization of ADHD. (From: [[https://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html|New York Times: The Selling of Attention Deficit Disorder]]) | ||
| </callout> | </callout> | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| - | == Prevalence == | + | ==== Prevalence ==== |
| <WRAP group> | <WRAP group> | ||
| <WRAP half column> | <WRAP half column> | ||
| - | Although many ADHD guidelines continue to suggest that prevalence rates are stable, and that overdiagnosis is not occurring, the epidemiological data is increasingly showing the opposite. A 2015 systematic review and meta-analysis (the most comprehensive to date) provided a conservative benchmark overall pooled estimate prevalence of 7.2% using 36 years of ADHD studies[([[https://www.ncbi.nlm.nih.gov/pubmed/25733754|Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.]])] In the United States, from 1997 to 2016, the estimated prevalence of diagnosed attention-deficit/hyperactivity disorder in US children and adolescents increased from 6.1% in 1997 to 10.2% in 2016.[([[https://www.ncbi.nlm.nih.gov/pubmed/30646132|Xu, G., Strathearn, L., Liu, B., Yang, B., & Bao, W. (2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA network open, 1(4), e181471-e181471.]])] This far exceeds the baseline estimated prevalence rates from the systematic review, suggesting that overdiagnosis may be occurring. | + | * Although many ADHD guidelines continue to suggest that prevalence rates are stable, and that overdiagnosis is not occurring, the epidemiological data is increasingly showing the opposite. |
| + | * A 2015 systematic review and meta-analysis (the most comprehensive to date) provided a conservative benchmark overall pooled estimate prevalence of 7.2% using 36 years of ADHD studies[([[https://www.ncbi.nlm.nih.gov/pubmed/25733754|Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.]])] | ||
| + | * In the United States, from 1997 to 2016, the estimated prevalence of diagnosed attention-deficit/hyperactivity disorder in US children and adolescents increased from 6.1% in 1997 to 10.2% in 2016.[([[https://www.ncbi.nlm.nih.gov/pubmed/30646132|Xu, G., Strathearn, L., Liu, B., Yang, B., & Bao, W. (2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA network open, 1(4), e181471-e181471.]])] | ||
| + | * This far exceeds the baseline estimated prevalence rates from the systematic review, suggesting that overdiagnosis may be occurring. | ||
| </WRAP> | </WRAP> | ||
| + | |||
| <WRAP half column> | <WRAP half column> | ||
| <callout> | <callout> | ||
| - | "If diagnoses from national or state population surveys exceed our estimate, then prima facie overdiagnosis of ADHD may be occurring for some children. If fewer, then underdiagnosis may be occurring."[([[https://www.ncbi.nlm.nih.gov/pubmed/25733754|Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.]])] | + | //"If diagnoses from national or state population surveys exceed our estimate, then prima facie overdiagnosis of ADHD may be occurring for some children. If fewer, then underdiagnosis may be occurring."//[([[https://www.ncbi.nlm.nih.gov/pubmed/25733754|Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.]])] |
| - | \\ \\ | + | |
| - | -- [[https://www.ncbi.nlm.nih.gov/pubmed/25733754|Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.]] | + | |
| </callout> | </callout> | ||
| <callout> | <callout> | ||
| - | "Over the 20-year period, the estimated prevalence of diagnosed ADHD in US children and adolescents increased from 6.1% in 1997-1998 to 10.2% in 2015-2016 (P for trend <.001)"[([[https://www.ncbi.nlm.nih.gov/pubmed/30646132|Xu, G., Strathearn, L., Liu, B., Yang, B., & Bao, W. (2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA network open, 1(4), e181471-e181471.]])] | + | //"Over the 20-year period, the estimated prevalence of diagnosed ADHD in US children and adolescents increased from 6.1% in 1997-1998 to 10.2% in 2015-2016 (P for trend <.001)"//[([[https://www.ncbi.nlm.nih.gov/pubmed/30646132|Xu, G., Strathearn, L., Liu, B., Yang, B., & Bao, W. (2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA network open, 1(4), e181471-e181471.]])] |
| + | </callout> | ||
| + | |||
| + | <callout> | ||
| + | //"The broadening of the diagnostic criteria in DSM-5 is likely to increase what is already a significant concern about overdiagnosis. It risks resulting in a diagnosis of ADHD being regarded with scepticism to the harm of those with severe problems who unquestionably need sensitive, skilled, specialist help and support."//[([[https://pubmed.ncbi.nlm.nih.gov/24192646/|Thomas, R., Mitchell, G. K., & Batstra, L. (2013). Attention-deficit/hyperactivity disorder: are we helping or harming?. Bmj, 347.]])] | ||
| \\ \\ | \\ \\ | ||
| - | -- [[https://www.ncbi.nlm.nih.gov/pubmed/30646132|Xu, G., Strathearn, L., Liu, B., Yang, B., & Bao, W. (2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA network open, 1(4), e181471-e181471.]] | + | -- [[https://www.reuters.com/article/idINL5N0IQ2X320131105|Rae Thomas]] |
| </callout> | </callout> | ||
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[https://slatestarcodex.com/2017/12/28/adderall-risks-much-more-than-you-wanted-to-know/|Slate Star Codex: Adderall Risks: Much More Than You Wanted To Know]]**</alert> | + | </WRAP> |
| + | </WRAP> | ||
| + | |||
| + | ==== Adult-onset ADHD ==== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500182/|Paris, J. et al. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed?. The Canadian Journal of Psychiatry, 60(7), 324-328.]]** | ||
| + | </alert> | ||
| + | |||
| + | * The most recent research has also called into question the validity of adult-onset ADHD diagnoses itself.[([[https://www.ncbi.nlm.nih.gov/pubmed/29050505|Sibley, Margaret H., et al. "Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25." American Journal of Psychiatry (2017)]])] Once considered a rare condition, the prevalence of adult ADHD has increased significantly.[([[https://www.ncbi.nlm.nih.gov/pubmed/26175391|Paris, J., Bhat, V., & Thombs, B. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed?. The Canadian Journal of Psychiatry, 60(7), 324-328.]])] | ||
| + | |||
| + | ==== Schools and Birth Month ==== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510202/|te Meerman, S. et al. (2017). ADHD: a critical update for educational professionals. International journal of qualitative studies on health and well-being, 12(sup1), 1298267.]]** | ||
| + | </alert> | ||
| + | |||
| + | * Children, in particular boys with summer birthdays (e.g. - August) entering kindergarten with a September 1st cutoff date are more likely to have teachers who perceive them as having more behavioural or academic difficulties. | ||
| + | * As a result, immature but age-normal behaviours may be mistaken for ADHD symptoms. | ||
| + | * These youngest children have a 34% higher chance of an ADHD diagnosis and a 32% higher chance of ADHD treatment than children with a September birthday (i.e - children are 1 year older than them). | ||
| + | |||
| + | ==== Misuse and Diversion ==== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377281/|Rasmussen, N. (2008). America’s first amphetamine epidemic 1929–1971: a quantitative and qualitative retrospective with implications for the present. American journal of public health, 98(6), 974-985.]]** | ||
| + | </alert> | ||
| + | |||
| + | <WRAP group> | ||
| + | <WRAP half column> | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See also: **[[meds:stimulants:1-misuse-diversion|]]** | ||
| + | </alert> | ||
| + | </WRAP> | ||
| + | <WRAP half column> | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://slatestarcodex.com/2017/12/28/adderall-risks-much-more-than-you-wanted-to-know/|Slate Star Codex: Adderall Risks: Much More Than You Wanted To Know]]** | ||
| + | </alert> | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| + | * Consider also the role of stimulant misuse and diversion during the assessment for ADHD.[([[http://www.tandfonline.com/doi/abs/10.1586/14737175.2014.908707|Graf, W. D., Miller, G., & Nagel, S. K. (2014). Addressing the problem of ADHD medication as neuroenhancements. Expert review of neurotherapeutics, 14(5), 569-581.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/18174822|Wilens, T. E., Adler, L. A., Adams, J., Sgambati, S., Rotrosen, J., Sawtelle, R., ... & Fusillo, S. (2008). Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. Journal of the American Academy of Child & Adolescent Psychiatry, 47(1), 21-31.]])] Long-term concurrent use of stimulants and opioids among adults with ADHD is common.[([[https://www.ncbi.nlm.nih.gov/pubmed/30485780|Layton, T. J., Barnett, M. L., Hicks, T. R., & Jena, A. B. (2018). Attention deficit–hyperactivity disorder and month of school enrollment. New England Journal of Medicine, 379(22), 2122-2130.]])] | ||
| - | == Adult ADHD == | ||
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500182/|Paris, J., Bhat, V., & Thombs, B. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed?. The Canadian Journal of Psychiatry, 60(7), 324-328.]]**</alert> | ||
| - | The most recent research has also called into question the validity of adult-onset ADHD diagnoses itself.[([[https://www.ncbi.nlm.nih.gov/pubmed/29050505|Sibley, Margaret H., et al. "Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25." American Journal of Psychiatry (2017)]])] Once considered a rare condition, the prevalence of adult ADHD has increased significantly.[([[https://www.ncbi.nlm.nih.gov/pubmed/26175391|Paris, J., Bhat, V., & Thombs, B. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed?. The Canadian Journal of Psychiatry, 60(7), 324-328.]])] | ||
| - | == Schools and Birth Month == | + | ==== Industry Influence ==== |
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510202/|te Meerman, S., Batstra, L., Grietens, H., & Frances, A. (2017). ADHD: a critical update for educational professionals. International journal of qualitative studies on health and well-being, 12(sup1), 1298267.]]**</alert> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| - | Children, in particular boys, with summer birthdays (e.g. - August) entering kindergarten with a September 1st cut off date are more likely to have teachers who perceive them as having more behavioural or academic difficulties. As a result, immature but age-normal behaviours may be mistaken for ADHD symptoms. These youngest children have a 34% higher chance of an ADHD diagnosis and a 32% higher chance of ADHD treatment than children with a September birthday (i.e - children are 1 year older than them). | + | See main article: **[[teaching:pharmaceutical-industry-influence|]]** |
| + | </alert> | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://www.newstatesman.com/science-tech/science-of-us/2021/12/why-im-wary-of-the-adhd-industrial-complex|The New Statesman: Why I’m wary of the ADHD industrial complex]]** | ||
| + | </alert> | ||
| - | == Misuse and Diversion == | + | ==== Technology ==== |
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[meds:stimulants:1-misuse-diversion|]]**</alert> | + | <WRAP group> |
| - | Consider also the role of stimulant misuse and diversion.[([[http://www.tandfonline.com/doi/abs/10.1586/14737175.2014.908707|Graf, W. D., Miller, G., & Nagel, S. K. (2014). Addressing the problem of ADHD medication as neuroenhancements. Expert review of neurotherapeutics, 14(5), 569-581.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/18174822|Wilens, T. E., Adler, L. A., Adams, J., Sgambati, S., Rotrosen, J., Sawtelle, R., ... & Fusillo, S. (2008). Misuse and diversion of stimulants prescribed for ADHD: a systematic review of the literature. Journal of the American Academy of Child & Adolescent Psychiatry, 47(1), 21-31.]])] Long-term concurrent use of stimulants and opioids among adults with ADHD is common.[([[https://www.ncbi.nlm.nih.gov/pubmed/30485780|Layton, T. J., Barnett, M. L., Hicks, T. R., & Jena, A. B. (2018). Attention deficit–hyperactivity disorder and month of school enrollment. New England Journal of Medicine, 379(22), 2122-2130.]])] | + | <WRAP half column> |
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See also: **[[addictions:non-substance:behavioural|]]** | ||
| + | </alert> | ||
| + | </WRAP> | ||
| + | <WRAP half column> | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://www.washingtonpost.com/news/the-intersect/wp/2015/03/25/is-the-internet-giving-us-all-adhd/?utm_term=.4b3f4d15a8f4|Washington Post: Is the Internet giving us all ADHD?]]** | ||
| + | </alert> | ||
| + | </WRAP> | ||
| + | </WRAP> | ||
| - | == Technology == | + | * Finally, consider also how the role of technology like smartphones and the Internet could be shaping and changing our attention spans.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220824/|Weiss, M. D., Baer, S., Allan, B. A., Saran, K., & Schibuk, H. (2011). The screens culture: impact on ADHD. ADHD Attention Deficit and Hyperactivity Disorders, 3(4), 327-334.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5403814/|Wilmer, H. H., Sherman, L. E., & Chein, J. M. (2017). Smartphones and cognition: A review of research exploring the links between mobile technology habits and cognitive functioning. Frontiers in psychology, 8, 605.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573248/|Tateno, M., Teo, A. R., Shirasaka, T., Tayama, M., Watabe, M., & Kato, T. A. (2016). Internet addiction and self‐evaluated attention‐deficit hyperactivity disorder traits among Japanese college students. Psychiatry and clinical neurosciences, 70(12), 567-572.]])] Our collective attention spans are getting shorter.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465266/|Lorenz-Spreen, P., Mønsted, B. M., Hövel, P., & Lehmann, S. (2019). Accelerating dynamics of collective attention. Nature communications, 10(1), 1759.]])] |
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[addictions:behavioural|]]**</alert> | + | |
| - | Finally, consider also how the role of technology like smartphones and the Internet could be shaping and changing our attention spans.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220824/|Weiss, M. D., Baer, S., Allan, B. A., Saran, K., & Schibuk, H. (2011). The screens culture: impact on ADHD. ADHD Attention Deficit and Hyperactivity Disorders, 3(4), 327-334.]])] | ||
| - | [([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5403814/|Wilmer, H. H., Sherman, L. E., & Chein, J. M. (2017). Smartphones and cognition: A review of research exploring the links between mobile technology habits and cognitive functioning. Frontiers in psychology, 8, 605.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573248/|Tateno, M., Teo, A. R., Shirasaka, T., Tayama, M., Watabe, M., & Kato, T. A. (2016). Internet addiction and self‐evaluated attention‐deficit hyperactivity disorder traits among Japanese college students. Psychiatry and clinical neurosciences, 70(12), 567-572.]])] Our collective attention spans are getting shorter.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465266/|Lorenz-Spreen, P., Mønsted, B. M., Hövel, P., & Lehmann, S. (2019). Accelerating dynamics of collective attention. Nature communications, 10(1), 1759.]])] | ||
| - | * [[https://www.washingtonpost.com/news/the-intersect/wp/2015/03/25/is-the-internet-giving-us-all-adhd/?utm_term=.4b3f4d15a8f4|Washington Post: Is the Internet giving us all ADHD?]] | + | ===== Screening and Rating Scales ===== |
| + | <callout type="danger" title="Attention!" icon="true"> | ||
| + | While rating scales are useful to support the clinical assessment and monitor symptoms, they should **never** be used on their own to make a diagnosis of ADHD. | ||
| + | </callout> | ||
| + | |||
| + | <panel title="Psychometric Scales for ADHD" no-body="true"> | ||
| + | <mobiletable 1> | ||
| + | ^ 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. | {{ :child:adhd_checklist.pdf |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. | {{ :child:adhd_snap-iv_26.pdf |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. | {{ :child:adult_adhd_self_report_scale.pdf |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 | [[https://www.pearsonassessments.com/store/usassessments/en/Store/Professional-Assessments/Behavior/Comprehensive/Conners-3rd-Edition/p/100000523.html|Link]] | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| + | |||
| + | ===== Pathophysiology ===== | ||
| + | * Recent research has shown that there are bilateral amygdala, accumbens, and hippocampus reductions in ADHD.[([[https://www.ncbi.nlm.nih.gov/pubmed/28219628|Hoogman, Martine, et al. "Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis." The Lancet Psychiatry 4.4 (2017): 310-319.]])] However, these findings have been scrutinized and remain under debate.[([[https://www.ncbi.nlm.nih.gov/pubmed/28495548|Hoogman, Martine, et al. "Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults–Authors' reply." The Lancet Psychiatry 4.6 (2017): 440-441.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/28495550|Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults]])] Like all psychiatric disorders, there is no single pathophysiological cause for ADHD and the diagnosis is based on behavioural criteria that are sensitive to subjectivity and cognitive biases.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510202/|te Meerman, S., Batstra, L., Grietens, H., & Frances, A. (2017). ADHD: a critical update for educational professionals. International journal of qualitative studies on health and well-being, 12(sup1), 1298267.]])] | ||
| + | * Implicated brain regions include the prefrontal cortex, basal ganglia, corpus callosum, and cerebellum .[([[https://pubmed.ncbi.nlm.nih.gov/16480802/|Krain, A. L., & Castellanos, F. X. (2006). Brain development and ADHD. Clinical psychology review, 26(4), 433-444.]])] | ||
| + | * Neurotransmitter systems involved include dopamine and norepinephrine. | ||
| ===== Differential Diagnosis ===== | ===== Differential Diagnosis ===== | ||
| + | **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 [[child:learning:psychoeducational-assessment|psychoeducational assessment]], including both cognitive and academic testing, to assess for learning problems. | ||
| + | |||
| <WRAP group> | <WRAP group> | ||
| <WRAP half column> | <WRAP half column> | ||
| == Psychiatric == | == Psychiatric == | ||
| * **[[child:disruptive-impulsive:odd|Oppositional defiant disorder (ODD)]]** | * **[[child:disruptive-impulsive:odd|Oppositional defiant disorder (ODD)]]** | ||
| + | * Children with ODD have distinct characteristics, including refusal to comply with rules, deliberately annoying others, blaming others for their own mistakes, and/or being spiteful or vindictive. Overlapping symptoms with ADHD include losing temper, anger, resentment, irritability, and argumentative behaviours | ||
| * **[[child:disruptive-impulsive:conduct-disorder|Conduct disorder]]** | * **[[child:disruptive-impulsive:conduct-disorder|Conduct disorder]]** | ||
| + | * The essential characteristic of conduct disorder is repetitive and persistent behavior such as violation of others' fundamental rights or of social rules/norms | ||
| * **[[child:disruptive-impulsive:dmdd|Disruptive mood dysregulation disorder (DMDD)]]** | * **[[child:disruptive-impulsive:dmdd|Disruptive mood dysregulation disorder (DMDD)]]** | ||
| * **[[child:learning:home|Specific learning disorder]]** | * **[[child:learning:home|Specific learning disorder]]** | ||
| Line 164: | Line 301: | ||
| * **[[ocd:1-ocd|Obsessive-compulsive disorder (OCD)]]** | * **[[ocd:1-ocd|Obsessive-compulsive disorder (OCD)]]** | ||
| * **[[mood:1-depression:home|Major depressive disorder (MDD)]]** | * **[[mood:1-depression:home|Major depressive disorder (MDD)]]** | ||
| - | * Moderate to severe depression should be treated first and suicide must be assessed in all cases | + | * A recent drop in mood is different from the lifelong demoralization that may be seen in ADHD. Moderate to severe depression should be treated first and suicide must be assessed in all cases |
| * **[[child:asd|Autism spectrum disorder (ASD)]]** | * **[[child:asd|Autism spectrum disorder (ASD)]]** | ||
| - | * **[[mood:bipolar-i|Bipolar I disorder]] or [[mood:bipolar-ii|Bipolar II disorder]]** | + | * Until the publication of the DSM-5, ASD was an exclusionary criterion in making the diagnosis of ADHD. Thus its relationship to ADHD remains poorly understood, between 30 to 70% of patients with ASD may meet criteria for ADHD |
| + | * **[[bipolar:bipolar-i|Bipolar I disorder]] or [[bipolar:bipolar-ii|Bipolar II disorder]]** | ||
| + | * Many symptoms of bipolar disorder overlap with ADHD symptoms (e.g. - insomnia, impulsive sexual behaviours, impulsivity), which can be diagnosis challenging. Bipolar disorder is distinct in that there is grandiosity, and episodic symptoms (versus chronic in ADHD) | ||
| + | * **[[:personality|Personality disorders]]** | ||
| + | * **[[personality:borderline|Borderline personality disorder]]** | ||
| + | * The symptoms of impulsivity, mood dysregulation, and poor concentration/focus may be better explained by BPD. | ||
| * **[[psychosis:home|Psychotic disorders]]** | * **[[psychosis:home|Psychotic disorders]]** | ||
| * **[[addictions:home|Substance use disorders]]** | * **[[addictions:home|Substance use disorders]]** | ||
| Line 172: | Line 314: | ||
| == Medication-related == | == Medication-related == | ||
| * **Medication with cognitive dulling side effect** | * **Medication with cognitive dulling side effect** | ||
| - | * Think about [[meds:mood-stabilizers:home|mood stabilizers]] and [[meds:antipsychotics:home|antipsychotics]] | + | * Think about [[meds:mood-stabilizers-anticonvulsants:home|mood stabilizers]] and [[meds:antipsychotics:home|antipsychotics]] |
| * **Medication with psychomotor activation** | * **Medication with psychomotor activation** | ||
| * Think about decongestants and beta agonists | * Think about decongestants and beta agonists | ||
| - | |||
| == Other Factors == | == Other Factors == | ||
| Line 182: | Line 323: | ||
| * **Child abuse or neglect** | * **Child abuse or neglect** | ||
| * **[[child:attachment:home|Attachment disorders]]** | * **[[child:attachment:home|Attachment disorders]]** | ||
| + | * **Intellectual giftedness** | ||
| + | * Individuals with giftedness may be misdiagnosed with ADHD in two ways. They may have high energy and over-excitability in school contexts (particularly in those with little academic stimulation), or individuals may meet full diagnostic criteria for ADHD but are able to concentrate for long periods of time, thus may not be diagnosed with ADHD. | ||
| </WRAP> | </WRAP> | ||
| <WRAP half column> | <WRAP half column> | ||
| - | |||
| == General Medical Conditions == | == General Medical Conditions == | ||
| * **[[sleep:home|Sleep disorders]]** | * **[[sleep:home|Sleep disorders]]** | ||
| * [[sleep:2-insomnia-disorder|Insomnia disorder]] | * [[sleep:2-insomnia-disorder|Insomnia disorder]] | ||
| + | * Insomnia in both children and adults can cause decreased attention, difficulties in emotional and behavioural regulation, decreased cognitive functioning (e.g., poor memory), and worse academic performance. Thus, a careful sleep history should be done to rule out the impact of sleep on the individuals symptoms. Additionally, stimulants can worsen sleep, and it is important to monitor for this | ||
| * [[sleep:breathing:1-osa|Obstructive sleep apnea]] or [[sleep:breathing:3-csa|central sleep apnea]] | * [[sleep:breathing:1-osa|Obstructive sleep apnea]] or [[sleep:breathing:3-csa|central sleep apnea]] | ||
| + | * Sleep apnea can mimic or aggravate ADHD symptoms, once sleep apnea is properly treated, ADHD symptoms may resolve on their own.[([[https://pubmed.ncbi.nlm.nih.gov/17157069/|Huang, Y. S., Guilleminault, C., Li, H. Y., Yang, C. M., Wu, Y. Y., & Chen, N. H. (2007). Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study. Sleep medicine, 8(1), 18-30.]])] | ||
| * **[[cl:tbi|Traumatic brain injury]]** | * **[[cl:tbi|Traumatic brain injury]]** | ||
| * Since underlying ADHD can increase risk for head trauma, it is important to look for timing of cognitive symptoms apparition (present before, or appeared or worsened after head trauma). | * Since underlying ADHD can increase risk for head trauma, it is important to look for timing of cognitive symptoms apparition (present before, or appeared or worsened after head trauma). | ||
| - | * **[[neurology:approaches:seizures|Seizure disorders]]** | + | * **[[neurology:approach-seizures|Seizure disorders]]** |
| + | * Absence seizures where an individual appears to lose attention or focus may be misdiagnosed as ADHD.[([[https://pubmed.ncbi.nlm.nih.gov/12662604/|Williams, J., Sharp, G. B., DelosReyes, E., Bates, S., Phillips, T., Lange, B., ... & Simpson, P. (2002). Symptom differences in children with absence seizures versus inattention. Epilepsy & Behavior, 3(3), 245-248.]])] | ||
| + | * Anti-epileptic medications side effects can impair attention and learning, may be confused with ADHD symptoms. | ||
| * **Hearing impairment or vision impairment** | * **Hearing impairment or vision impairment** | ||
| * Order audiology and vision assessment if there are any concerns | * Order audiology and vision assessment if there are any concerns | ||
| Line 211: | Line 357: | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| - | ===== Pathophysiology ===== | ||
| - | Recent research has shown that there are bilateral amygdala, accumbens, and hippocampus reductions in ADHD.[([[https://www.ncbi.nlm.nih.gov/pubmed/28219628|Hoogman, Martine, et al. "Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis." The Lancet Psychiatry 4.4 (2017): 310-319.]])] However, these findings have been scrutinized and remain under debate.[([[https://www.ncbi.nlm.nih.gov/pubmed/28495548|Hoogman, Martine, et al. "Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults–Authors' reply." The Lancet Psychiatry 4.6 (2017): 440-441.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/28495550|Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults]])] | + | ===== Investigations ===== |
| + | * Laboratory and imaging tests if indicated by the clinical evaluation. | ||
| + | |||
| + | ===== Physical Exam ===== | ||
| + | * Hearing and visual tests if clinically indicated. | ||
| ===== Treatment ===== | ===== Treatment ===== | ||
| + | <callout type="danger" title="Never Forget this Principle!" icon="true"> | ||
| + | When thinking about treatment of ADHD, always remember this core principle: | ||
| + | * Psychoeducation and support //**for all**// | ||
| + | * Behavioural treatments //**for most**// | ||
| + | * Medications //**for some**// | ||
| + | </callout> | ||
| + | ==== Psychoeducation ==== | ||
| + | <WRAP group> | ||
| + | <WRAP half column> | ||
| + | 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.[([[https://pubmed.ncbi.nlm.nih.gov/24080677/|Bai, G. N., Wang, Y. F., Yang, L., & Niu, W. Y. (2015). Effectiveness of a focused, brief psychoeducation program for parents of ADHD children: improvement of medication adherence and symptoms. Neuropsychiatric Disease and Treatment, 11, 2721.]])] It has been found to increase knowledge, enhance treatment adherence, and improve attitudes and intended behaviours towards the person with ADHD.[([[https://pubmed.ncbi.nlm.nih.gov/23461278/|Nussey, C., Pistrang, N., & Murphy, T. (2013). How does psychoeducation help? A review of the effects of providing information about Tourette syndrome and attention‐deficit/hyperactivity disorder. Child: care, health and development, 39(5), 617-627.]])] Psychoeducation typically involves: | ||
| + | * Explaining the rationale for the diagnosis, referencing examples of symptoms and impairment given by the parents and child/adolescent | ||
| + | * Explaining that although ADHD has a genetic component, environmental interventions can still be immensely helpful | ||
| + | * Reviewing the natural course and prognosis of ADHD and discuss comorbid conditions | ||
| + | * Discussing available treatment options (both pharmacological and non-pharmacological) | ||
| + | * Conveying a message of hope and optimism, telling the patient and family that ADHD tends to improve over time and is among the most treatable of psychiatric disorders | ||
| + | </WRAP> | ||
| - | ==== Stimulants ==== | + | <WRAP half column> |
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See main article: **[[meds:stimulants:1-misuse-diversion|]]**</alert> | + | <HTML> |
| + | <div id="amazon"> | ||
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| + | <p> | ||
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| + | <small> | ||
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| + | </div> | ||
| + | </HTML> | ||
| + | </WRAP> | ||
| + | </WRAP> | ||
| - | <callout type="info" title="Stimulants and Risk of Psychosis" icon="true"> | + | ==== Behavioural and Psychosocial ==== |
| - | In adolescents and young adults with ADHD, the risk of new-onset psychosis occurs in approximately 1 in 660 patients, and [[meds:stimulants:amphetamine:home|amphetamine]] use is associated with a two-fold greater risk of psychosis than with [[meds:stimulants:2-methylphenidate:home|methylphenidate]].[([[https://www.ncbi.nlm.nih.gov/pubmed/30893533|Moran, L. V., Ongur, D., Hsu, J., Castro, V. M., Perlis, R. H., & Schneeweiss, S. (2019). Psychosis with Methylphenidate or Amphetamine in Patients with ADHD. New England Journal of Medicine, 380(12), 1128-1138.]])] | + | Planning and organization skills may be suboptimal in individuals with ADHD.[([[https://pubmed.ncbi.nlm.nih.gov/28714075/|Kofler, M. J., Sarver, D. E., Harmon, S. L., Moltisanti, A., Aduen, P. A., Soto, E. F., & Ferretti, N. (2018). Working memory and organizational skills problems in ADHD. Journal of Child Psychology and Psychiatry, 59(1), 57-67.]])] 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.[([[https://pubmed.ncbi.nlm.nih.gov/24245813/|Evans, S. W., Owens, J. S., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 43(4), 527-551.]])] |
| - | </callout> | + | |
| - | ==== Trigeminal Nerve Stimulation ==== | + | <WRAP group> |
| - | * [[https://www.ncbi.nlm.nih.gov/m/pubmed/30768393/|McGough, J. J., Sturm, A., Cowen, J., Tung, K., Salgari, G. C., Leuchter, A. F., ... & Loo, S. K. (2019). Double-Blind, Sham-Controlled, Pilot Study of Trigeminal Nerve Stimulation for Attention-Deficit/Hyperactivity Disorder.]] | + | <WRAP half column> |
| + | <panel type="info" title="Home Interventions" subtitle="Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" no-body="true" footer=""> | ||
| + | ^ Instructional | • Get eye and/or gentle physical contact before giving one or two clear instructions.\\ • Get the person to repeat the instructions before proceeding. | | ||
| + | ^ 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. | | ||
| + | </panel> | ||
| - | ==== Supplements ==== | + | <panel type="info" title="Workplace Interventions" subtitle="Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" no-body="true" footer=""> |
| - | There is some evidence that supplementing diets of pediatric ADHD patients with fatty fish high in omega-3s or commercial preparations containing at least 500 mg of EPA can reduce symptoms.[([[https://www.ncbi.nlm.nih.gov/pubmed/28741625|Chang J-C et al. Omega-3 polyunsaturated fatty acids in youths with attention deficit hyperactivity disorder (ADHD): A systematic review and meta-analysis of clinical trials and biological studies. Neuropsychopharmacology 2017 Jul 25]])] | + | ^ 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. | |
| + | </panel> | ||
| - | ===== Resources ===== | + | </WRAP> |
| + | <WRAP half column> | ||
| + | <panel type="info" title="School Interventions" subtitle="Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" no-body="true" footer=""> | ||
| + | ^ 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”. | | ||
| + | ^ 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. | | ||
| + | </panel> | ||
| + | </WRAP> | ||
| + | </WRAP> | ||
| + | |||
| + | ==== Manualized and Other Interventions ==== | ||
| + | Many types of standardized, or structured behavioural interventions have been investigated, including: | ||
| + | * Parent Management Training Models | ||
| + | * For preschool-aged children, parent management training models, such as parent–child interaction therapy (PCIT), the Incredible Years programs, the New Forest Program, Triple P (Positive Parenting Program), and Helping the Noncompliant Child, are effective in decreasing symptoms of ADHD and disruptive behaviour disorders.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400193/|Abikoff, H. B., Thompson, M., Laver‐Bradbury, C., Long, N., Forehand, R. L., Miller Brotman, L., ... & Sonuga‐Barke, E. (2015). Parent training for preschool ADHD: a randomized controlled trial of specialized and generic programs. Journal of Child Psychology and Psychiatry, 56(6), 618-631.]])] | ||
| + | * Social Skills Training (SST) | ||
| + | * SST teaches children how to perceive and interpret subtle social cues and problem-solve in social interactions | ||
| + | * [[psychotherapy:cbt|Cognitive Behavioural Therapy]] | ||
| + | * In CBT targeted for ADHD, time management and organizational skills are addressed.[([[https://pubmed.ncbi.nlm.nih.gov/29566425/|Lopez, P. L., Torrente, F. M., Ciapponi, A., Lischinsky, A. G., Cetkovich‐Bakmas, M., Rojas, J. I., ... & Manes, F. F. (2018). Cognitive‐behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews, (3).]])] | ||
| + | * [[psychotherapy:mindfulness|Mindfulness Training]] | ||
| + | * Can lessen ADHD symptoms such as hyperactivity/impulsivity and attention problems, emotional dysregulation, while increasing self- directedness and self-regulation. Importantly, compared to stimulants, these improvements can be maintained over time.[([[https://pubmed.ncbi.nlm.nih.gov/18025249/|Zylowska, L., Ackerman, D. L., Yang, M. H., Futrell, J. L., Horton, N. L., Hale, T. S., ... & Smalley, S. L. (2008). Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. Journal of attention disorders, 11(6), 737-746.]])] | ||
| + | * Other interventions include: behavioural parent training , behavioural classroom management, behavioural peer intervention , combined behaviour management interventions, organization training | ||
| + | |||
| + | ==== Pharmacotherapy ==== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See also main articles: ** [[meds:stimulants:home|]]** and **[[meds:stimulants:1-misuse-diversion|]]** | ||
| + | </alert> | ||
| + | Stimulants are considered the main treatment in ADHD in adolescents and adults, and there are two main classes of medications: [[meds:stimulants:amphetamine:home|amphetamines]] and [[meds:stimulants:2-methylphenidate:home|methylphenidate]] (both classes are available in short, intermediary and long-acting preparations). The average response rate to medications is about 70%.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3063150/|Molina, B. S., Hinshaw, S. P., Swanson, J. M., Arnold, L. E., Vitiello, B., Jensen, P. S., ... & MTA Cooperative Group. (2009). The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child & Adolescent Psychiatry, 48(5), 484-500.]])] 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.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3842881/|Ramtvedt, B. E., Røinås, E., Aabech, H. S., & Sundet, K. S. (2013). Clinical gains from including both dextroamphetamine and methylphenidate in stimulant trials. Journal of child and adolescent psychopharmacology, 23(9), 597-604.]])] While there is considerable data support the short-term benefits of ADHD treatment, there is little evidence that it improves long-term functional outcomes.[([[https://pubmed.ncbi.nlm.nih.gov/30071978/|Ramos-Olazagasti, M. A., Castellanos, F. X., Mannuzza, S., & Klein, R. G. (2018). Predicting the adult functional outcomes of boys with ADHD 33 years later. Journal of the American Academy of Child & Adolescent Psychiatry, 57(8), 571-582.]])][([[https://pubmed.ncbi.nlm.nih.gov/22344318/|Serra-Pinheiro, M. A., Coutinho, E. S., Souza, I. S., Pinna, C., Fortes, D., Araújo, C., ... & Mattos, P. (2013). Is ADHD a risk factor independent of conduct disorder for illicit substance use? A meta-analysis and metaregression investigation. Journal of attention disorders, 17(6), 459-469.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3597443/|Klein, R. G., Mannuzza, S., Olazagasti, M. A. R., Roizen, E., Hutchison, J. A., Lashua, E. C., & Castellanos, F. X. (2012). Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Archives of general psychiatry, 69(12), 1295-1303.]])] The general ADHD treatment principles are:[(Adapted from: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018)] | ||
| <WRAP group> | <WRAP group> | ||
| - | <WRAP quarter column> | + | <WRAP half column> |
| - | ==== For Patients ==== | + | - Long-acting stimulants are preferred as first-line treatment agents. |
| - | * [[https://www.amazon.ca/Taking-Charge-Adult-Russell-Barkley/dp/1606233386|Amazon: Taking Charge of Adult ADHD]] | + | * There should be an adequate trial of **both** classes of long-acting stimulants before moving onto a trial of a second-line agent. |
| + | - Short- and intermediate-acting stimulants, and non-stimulants (i.e. - [[meds:alpha-2-adrenergic-agonist:guanfacine|guanfacine]], [[meds:antidepressants:selective-nri:atomoxetine|atomoxetine]]) are second-line treatment agents, and can be used for patients who experience significant side effects on first-line agents, have had poor response on first-line, or do not have access to first-line medications[([[https://pubmed.ncbi.nlm.nih.gov/15322961/|Ramtvedt, B. E., Røinås, E., Aabech, H. S., & Sundet, K. S. (2013). Clinical gains from including both dextroamphetamine and methylphenidate in stimulant trials. Journal of child and adolescent psychopharmacology, 23(9), 597-604.]])] | ||
| + | * Second-line //stimulants// can additionally be used for: | ||
| + | * As a PRN for certain activities, and/or | ||
| + | * To augment long-acting formulations early or late in the day, or early in the evening | ||
| + | * Second-line **non-stimulants** can also be used: | ||
| + | * In combination with first-line agents as a potential augmentation for first-line treatment suboptimal responders | ||
| + | * In patients where stimulants are contraindicated (e.g. - high risk of [[meds:stimulants:1-misuse-diversion|stimulant misuse or diversion]]) | ||
| + | - Third-line treatments include agents such as [[meds:antidepressants:ndri:bupropion|bupropion]], [[meds:alpha-2-adrenergic-agonist:clonidine|clonidine]], [[meds:antidepressants:tca:imipramine|imipramine]], modafinil, and [[meds:antipsychotics:second-gen-atypical:home|atypical antipsychotics]]. These medications are off-label use, and may be used in adjunct with other first or second line agents. These medications have higher risks, higher side-effect profile, or lower efficacy. | ||
| + | * There is no significant difference between picking clonidine and guanfacine in terms of efficacy as an adjunct. | ||
| + | </WRAP> | ||
| + | <WRAP half column> | ||
| + | <callout type="danger" title="It's Not Just About the Meds!" icon="true"> | ||
| + | Pharmacological treatment for ADHD must be integrated in a multimodal approach (i.e. - a [[teaching:biopsychosocial-case-formulation|biopsychosocial]] that implements psychoeducation, psychosocial interventions, and manualized interventions), plus a medical evaluation and ongoing follow-up. Comorbid disorders and co-administration of other medications must also be taken into account. | ||
| + | </callout> | ||
| + | <callout type="question" icon="true" title="How Do I Choose Between Amphetamine vs. Methylphenidate?"> | ||
| + | * There is no overwhelming evidence to suggest picking one class of medications over another. | ||
| + | * Depends on multiple factors: | ||
| + | * Does the child require coverage in the evenings? | ||
| + | * How concerned is the family regarding potential interference with sleep and appetite? | ||
| + | * Does the family prefer convenience or control/flexibility? | ||
| + | * How would the child feel about taking medication at school? | ||
| + | * Is there a risk of abuse or diversion of the stimulant? | ||
| + | * What is the family’s financial/insurance situation? | ||
| + | </callout> | ||
| + | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| - | <WRAP quarter column> | + | <panel type="info" title="1st Line: Long-Acting Stimulants for ADHD" subtitle="Adapted from: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" no-body="true" footer="* = Doses per CADDRA that are over or under product monograph maximum or minimum doses should be considered off-label use."> |
| + | <mobiletable 1> | ||
| + | ^ 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*) ^ | ||
| + | ^ [[meds:stimulants:amphetamine:adderall|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) | | ||
| + | ^ [[meds:stimulants:2-methylphenidate:biphentin|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) | | ||
| + | ^ [[meds:stimulants:2-methylphenidate:concerta|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) | | ||
| + | ^ [[meds:stimulants:amphetamine:lisdexamfetamine|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) | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| + | |||
| + | <panel type="info" title="2nd Line: Short- and Intermediate-Acting Stimulants for ADHD" subtitle="Adapted from: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" no-body="true" footer="* = Doses per CADDRA that are over or under product monograph maximum or minimum doses should be considered off-label use."> | ||
| + | <mobiletable 1> | ||
| + | ^ 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*) ^ | ||
| + | ^ [[meds:stimulants:amphetamine:dextroamphetamine|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) | | ||
| + | ^ [[meds:stimulants:amphetamine:dextroamphetamine|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) | | ||
| + | ^ [[meds:stimulants:2-methylphenidate:ritalin|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) | | ||
| + | ^ [[meds:stimulants:2-methylphenidate:ritalin|Ritalin SR]] | Methylphenidate | 20 mg tab | 20 mg q AM | ↑ 20 mg | 60 mg (60 mg) | 60 mg (80 mg) | 60 mg (100 mg) | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| + | |||
| + | <panel type="info" title="2nd Line: Non-Stimulants for ADHD" subtitle="Adapted from: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" no-body="true" footer="* = Doses per CADDRA that are over or under product monograph maximum or minimum doses should be considered off-label use."> | ||
| + | <mobiletable 1> | ||
| + | ^ 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 | [[meds:alpha-2-adrenergic-agonist:guanfacine|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 | [[meds:antidepressants:selective-nri:atomoxetine|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 | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| + | ==== Pharmacotherapy: Monitoring==== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://pediatrics.aappublications.org/content/122/2/451|Perrin, James M., et al. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics 122.2 (2008): 451-453.]]** | ||
| + | </alert> | ||
| + | <WRAP group> | ||
| + | <WRAP half column> | ||
| + | Having an approach to prescribing can help the clinician assess whether a medication is working, and provides a systematic approach to monitoring prescribing: | ||
| + | - Start the medication on weekend so parents can see how the child responds to the drug throughout the day (not on a school day!) | ||
| + | * Educating parents about the length of action of each medication is very important! | ||
| + | * Children may appear "not be responding" because the effect of the medication has actually worn off by the time they come home from school | ||
| + | - Wait approximately 1 week to see if they are having a good response to the medication before making any changes | ||
| + | * This different than titrating an antidepressant where one might wait longer | ||
| + | - Titrating the medication: | ||
| + | * Start low and titrate the dose by small increments, and monitor closely | ||
| + | * Continue the titration until one of these events happen: | ||
| + | * Optimal response is achieved | ||
| + | * Intolerable adverse effects develop | ||
| + | * Maximum dose is reached | ||
| + | * The trick is finding the "sweet spot" dose -- not too low such that there is no effect, and not too high that it causes side effects | ||
| + | - If there is non-response, also consider trying a different formulation in the same class (methylphenidate or amphetamine) before switching to another class. | ||
| + | </WRAP> | ||
| + | <WRAP half column> | ||
| + | <callout type="success" title="Stimulant Medication Checklist" icon="true"> | ||
| + | * There should be precaution in starting stimulants in individuals with a history of cardiac disease, bipolar disorder, psychosis, and/or pregnancy and lactation. | ||
| + | * Always measure initial weight and height in children and adolescents, with ongoing measurements throughout treatment and referencing percentile charts and growth charts. | ||
| + | * Cardiovascular exam should include blood pressure and heart rate measurement | ||
| + | * On average, stimulants increase heart rate (HR) by 5-10 beats/min, and systolic blood pressure (SBP) by 4-6 mmHg.[([[https://pubmed.ncbi.nlm.nih.gov/21961773/|Hammerness, P. G., Perrin, J. M., Shelley-Abrahamson, R., & Wilens, T. E. (2011). Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity disorder: update and clinical recommendations. Journal of the American Academy of Child & Adolescent Psychiatry, 50(10), 978-990.]])] | ||
| + | * Any history of cardiac disease, physical exam suggestive of cardiac disease, and/or family history of sudden cardiac death should make you consider additional investigations (e.g. - ECG) prior to starting treatment. | ||
| + | * Routine ECG screening prior to starting a stimulant is controversial.[([[https://pubmed.ncbi.nlm.nih.gov/24141829/|Shahani, S. A., Evans, W. N., Mayman, G. A., & Thomas, V. C. (2014). Attention deficit hyperactivity disorder screening electrocardiograms: a community-based perspective. Pediatric cardiology, 35(3), 485-489.]])][(Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018)] | ||
| + | * Blood pressure measurement should be taken both when patient is off medication and on medication, in order to assess the contribution by medications. | ||
| + | * Assess for sleep quality at baseline and monitor for tics if present. | ||
| + | </callout> | ||
| + | </WRAP> | ||
| + | </WRAP> | ||
| + | |||
| + | <panel type="info" title="Contraindications, Precautions, and Monitoring in ADHD Medications" subtitle="Adapted from: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" footer="* = Atomoxetine can be used in combination with inhaled beta2 agonists such as salbutamol, but should be used with caution in patients on oral or IV beta2 agonists. † = Rare cases of priapism have been associated with methylphenidate and atomoxetine. The risk not well quantified, but appears to be greater with atomoxetine. ‡ = There is little evidence to establish that these drugs cause suicidal thoughts and behaviours, but it is possible that they may contribute to the risk." no-body="true"> | ||
| + | <mobiletable 1> | ||
| + | ^ Class ^ Contraindications ^ Precautions ^ Monitoring during Treatment ^ | ||
| + | ^ Any ADHD medication | Known hypersensitivity or allergy to the products | • Cardiac disease\\ • [[bipolar:bipolar-i|Bipolar disorder]]\\ • [[psychosis:home|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:home|Sleep]], appetite\\ • Irritability or mood swings | | ||
| + | ^ [[meds:stimulants:home|Stimulants]] | • Treatment with [[meds:antidepressants:maoi:home|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 [[bipolar:bipolar-i|mania]] or [[psychosis:home|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 | | ||
| + | ^ [[meds:antidepressants:selective-nri:atomoxetine|Atomoxetine]] | • Treatment with [[meds:antidepressants:maoi:home|MAOI]] or RIMA and for up to 14 days after discontinuation.\\ • Narrow angle glaucoma\\ • Uncontrolled [[cl:thyroid-disorders:hyperthyroidism|hyperthyroidism]]\\ • Pheochromocytoma\\ • Moderate to severe hypertension\\ • Symptomatic cardiovascular disease\\ • Severe cardiovascular disorders\\ • Advanced arteriosclerosis | • Asthma*\\ • [[meds:cytochrome-p450|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 | | ||
| + | ^ [[meds:alpha-2-adrenergic-agonist:home|Alpha-2 Agonists]] (e.g. - [[meds:alpha-2-adrenergic-agonist:guanfacine|guanfacine]], [[meds:alpha-2-adrenergic-agonist:clonidine|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\\ • [[meds:qtc|QTc interval]] (to be monitored if underlying conditions or other medication increase the risk of prolonged QTc interval) | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| + | ==== Pharmacotherapy: Side Effects and Adverse Events ==== | ||
| + | <panel type="info" title="Common Side Effects in ADHD Medications" subtitle="Adapted from: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018" no-body="true"> | ||
| + | <mobiletable 1> | ||
| + | ^ ^ 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 | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| + | |||
| + | <callout type="info" title="Stimulants and the Risk of Psychosis and Mania" icon="true"> | ||
| + | Stimulant prescription and use is not without risks: | ||
| + | * In patients with diagnosed [[bipolar:bipolar-i|bipolar disorder]], there is a small risk of switching from euthymia or depression to mania when prescribed a stimulant medication. | ||
| + | * If this occurs, the stimulant should be tapered or discontinued, and treatment of mania and bipolar disorder should be prioritized. Stimulant medication may carefully titrated (start low and go slow) once mood symptoms are stabilized.[([[https://pubmed.ncbi.nlm.nih.gov/15625202/|Scheffer, R. E., Kowatch, R. A., Carmody, T., & Rush, A. J. (2005). Randomized, placebo-controlled trial of mixed amphetamine salts for symptoms of comorbid ADHD in pediatric bipolar disorder after mood stabilization with divalproex sodium. American Journal of Psychiatry, 162(1), 58-64.]])] | ||
| + | * In adolescents and young adults with ADHD, the risk of new-onset psychosis occurs in approximately 1 in 660 patients, and [[meds:stimulants:amphetamine:home|amphetamine]] use is associated with a two-fold greater risk of psychosis than with [[meds:stimulants:2-methylphenidate:home|methylphenidate]].[([[https://www.ncbi.nlm.nih.gov/pubmed/30893533|Moran, L. V., Ongur, D., Hsu, J., Castro, V. M., Perlis, R. H., & Schneeweiss, S. (2019). Psychosis with Methylphenidate or Amphetamine in Patients with ADHD. New England Journal of Medicine, 380(12), 1128-1138.]])] | ||
| + | </callout> | ||
| + | <callout type="info" title="Stimulants in Tic Disorders and Tourette's" icon="true"> | ||
| + | * Stimulant medications are a safe and effective treatment for ADHD in individuals with [[child:motor:tic-disorders|tic disorders]] but requires careful monitoring for the potential for worsening of tics.[([[https://pubmed.ncbi.nlm.nih.gov/9136492/|Castellanos, F. X., Giedd, J. N., Elia, J., Marsh, W. L., Ritchie, G. F., Hamburger, S. D., & Rapoport, J. L. (1997). Controlled stimulant treatment of ADHD and comorbid Tourette's syndrome: effects of stimulant and dose. Journal of the American Academy of Child & Adolescent Psychiatry, 36(5), 589-596.]])] Stimulants do not typically raise the risk of tics but may do so in rare cases. | ||
| + | </callout> | ||
| + | |||
| + | ==== Pharmacotherapy: Outcomes ==== | ||
| + | <callout type="question" icon="true" title="What's the Long-term Evidence for Stimulants in ADHD?"> | ||
| + | The Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder, or MTA, is the largest long-term follow up study on stimulant treatment for ADHD.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3063150/|Abikoff, H., & Hechtman, L. (1995). Multimodal treatment study of children with attention deficit hyperactivity disorder. In annual meeting of the International Society for Research in Child and Adolescent Psychopathology, London.]])][([[https://pubmed.ncbi.nlm.nih.gov/17667478/|Jensen, P. S., Arnold, L. E., Swanson, J. M., Vitiello, B., Abikoff, H. B., Greenhill, L. L., ... & Hur, K. (2007). 3-year follow-up of the NIMH MTA study. Journal of the American Academy of Child & Adolescent Psychiatry, 46(8), 989-1002.]])] At the 8-year follow up mark, the study drew the following conclusions: | ||
| + | * //"Although the MTA data provided strong support for the acute reduction of symptoms with intensive medication management, these long-term follow-up data fail to provide support for long-term advantage of medication treatment beyond two years for the majority of children."// | ||
| + | * //"Overall, the findings of this 6- and 8-year follow-up of the children in the MTA indicate that [...] treatment-related improvements for the children in the MTA are generally maintained, **but differential treatment efficacy continues to be lost at and beyond 36-months**"// | ||
| + | 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 [[https://www.nimh.nih.gov/archive/news/2009/short-term-intensive-treatment-not-likely-to-improve-long-term-outcomes-for-children-with-adhd|NIMH MTA website]] and [[https://www.nimh.nih.gov/funding/clinical-research/practical/mta/the-multimodal-treatment-of-attention-deficit-hyperactivity-disorder-study-mtaquestions-and-answers|MTA FAQ]] also acknowledges the modest benefits of long-term treatment. Other population studies have also suggested this finding as well.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4815037/|Currie, J., Stabile, M., & Jones, L. (2014). Do stimulant medications improve educational and behavioural outcomes for children with ADHD?. Journal of health economics, 37, 58-69.]])] 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.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6168061/|Swanson, J. M., Arnold, L. E., Molina, B. S., Sibley, M. H., Hechtman, L. T., Hinshaw, S. P., ... & Stern, K. (2017). Young adult outcomes in the follow‐up of the multimodal treatment study of attention‐deficit/hyperactivity disorder: Symptom persistence, source discrepancy, and height suppression. Journal of Child Psychology and Psychiatry, 58(6), 663-678.]])] | ||
| + | </callout> | ||
| + | * ADHD medications have been shown in population registry studies to be //associated// with reduced mortality from unnatural causes, motor vehicle crashes, and possibly substance use disorders.[([[https://pubmed.ncbi.nlm.nih.gov/38470385/|Li, L., Zhu, N., Zhang, L., Kuja-Halkola, R., D’Onofrio, B. M., Brikell, I., ... & Chang, Z. (2024). ADHD Pharmacotherapy and Mortality in Individuals With ADHD. JAMA, 331(10), 850-860.]])] | ||
| + | * Other analyses using more robust data from the MTA study have shown no difference in the impact on substance use disorder risk.[([[https://pubmed.ncbi.nlm.nih.gov/37405756/|Molina, B. S., Kennedy, T. M., Howard, A. L., Swanson, J. M., Arnold, L. E., Mitchell, J. T., ... & Vitiello, B. (2023). Association between stimulant treatment and substance use through adolescence into early adulthood. JAMA psychiatry, 80(9), 933-941.]])] | ||
| + | * Long-term exposure to ADHD medications, in particular stimulant medications is associated with an increased risk of cardiovascular disease, specifically hypertension and arterial disease. | ||
| + | ==== Other Treatments ==== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://www.nytimes.com/2014/11/02/opinion/sunday/a-natural-fix-for-adhd.html|New York Times: A Natural Fix for A.D.H.D.]]** | ||
| + | </alert> | ||
| + | |||
| + | * There is some evidence that fatty fish high in Omega-3s or commercial preparations containing at least 500 mg of EPA can reduce symptoms.[([[https://www.ncbi.nlm.nih.gov/pubmed/28741625|Chang J-C et al. Omega-3 polyunsaturated fatty acids in youths with attention deficit hyperactivity disorder (ADHD): A systematic review and meta-analysis of clinical trials and biological studies. Neuropsychopharmacology 2017 Jul 25]])] | ||
| + | * Restricting artificial food colours have been found to be potentially effective (but modest) in a meta-analysis.[([[https://pubmed.ncbi.nlm.nih.gov/23360949/|Sonuga-Barke, E. J., Brandeis, D., Cortese, S., Daley, D., Ferrin, M., Holtmann, M., ... & European ADHD Guidelines Group. (2013). Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. American Journal of Psychiatry, 170(3), 275-289.]])] | ||
| + | * Polyunsaturated fatty acids (PUFAs) supplementation may help, due to a though of deficiency of PUFAs in ADHD.[([[https://pubmed.ncbi.nlm.nih.gov/24560325/|Puri, B. K., & Martins, J. G. (2014). Which polyunsaturated fatty acids are active in children with attention-deficit hyperactivity disorder receiving PUFA supplementation? A fatty acid validated meta-regression analysis of randomized controlled trials. Prostaglandins, Leukotrienes and Essential Fatty Acids, 90(5), 179-189.]])] | ||
| + | * Animal studies indicates that [[teaching:exercise-prescription|exercise]] enhances brain development and overall behavioural functioning. Studies in children with ADHD suggest that both short-term (≥20 minutes) and long-term (≥5 weeks) of moderate-to-vigorous physical activity can improve ADHD symptoms and neuropsychological functioning.[([[https://pubmed.ncbi.nlm.nih.gov/25220093/|Halperin, J. M., Berwid, O. G., & O’Neill, S. (2014). Healthy body, healthy mind?: the effectiveness of physical activity to treat ADHD in children. Child and Adolescent Psychiatric Clinics, 23(4), 899-936.]])] | ||
| + | * Trigeminal nerve stimulation has been studied and has an estimated treatment effect size similar to non-stimulants.[([[https://www.ncbi.nlm.nih.gov/m/pubmed/30768393/|McGough, J. J. et al. (2019). Double-Blind, Sham-Controlled, Pilot Study of Trigeminal Nerve Stimulation for Attention-Deficit/Hyperactivity Disorder.]])] | ||
| + | |||
| + | |||
| + | |||
| + | |||
| + | ===== Guidelines ===== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[teaching:clinical-practice-guidelines-cpg|]]**</alert> | ||
| + | |||
| + | {{page>teaching:clinical-practice-guidelines-cpg#adhd&nouser&noheader&nodate&nofooter}} | ||
| + | |||
| + | ===== Resources ===== | ||
| + | |||
| + | <WRAP group> | ||
| + | <WRAP third column> | ||
| ==== For Providers ==== | ==== For Providers ==== | ||
| + | * **[[https://www.nature.com/articles/nrdp201520|Faraone, S. et al. Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers 1, 15020 (2015)]]** | ||
| * [[https://caddra.ca/|CADDRA: The Canadian ADHD Resource Alliance (Guidelines)]] | * [[https://caddra.ca/|CADDRA: The Canadian ADHD Resource Alliance (Guidelines)]] | ||
| + | * [[https://www.caddra.ca/pdfs/Medication_Chart_English_CANADA.pdf|CADDRA Guide to ADHD Pharmacological Treatments in Canada (PDF)]] | ||
| * [[https://slatestarcodex.com/2017/12/28/adderall-risks-much-more-than-you-wanted-to-know/|Slate Star Codex: Adderall Risks: Much More Than You Wanted To Know]] | * [[https://slatestarcodex.com/2017/12/28/adderall-risks-much-more-than-you-wanted-to-know/|Slate Star Codex: Adderall Risks: Much More Than You Wanted To Know]] | ||
| </WRAP> | </WRAP> | ||
| - | <WRAP quarter column> | + | |
| - | == Contrarian Views == | + | <WRAP third column> |
| + | == Sober Second Thought == | ||
| * [[https://www.youtube.com/watch?v=JowPOqRmxNs|YouTube: Dr Russell Barkley ADHD Intention Deficit Disorder]] | * [[https://www.youtube.com/watch?v=JowPOqRmxNs|YouTube: Dr Russell Barkley ADHD Intention Deficit Disorder]] | ||
| + | * [[https://www.psychologytoday.com/us/blog/finding-purpose/202101/is-adhd-real-disorder-or-one-end-normal-continuum|PsychologyToday: Is ADHD a Real Disorder or One End of a Normal Continuum?]] | ||
| * [[http://www.psychiatryletter.org/clinical-files-2-january-2016.html|ADHD: A Clinician's Concern]] | * [[http://www.psychiatryletter.org/clinical-files-2-january-2016.html|ADHD: A Clinician's Concern]] | ||
| * [[https://slate.com/human-interest/2013/12/selling-adhd-new-york-times-reports-on-the-big-business-of-attention-deficit-hyperactivity-disorder.html|Slate: Who Wouldn’t Want an Adderall Prescription?]] | * [[https://slate.com/human-interest/2013/12/selling-adhd-new-york-times-reports-on-the-big-business-of-attention-deficit-hyperactivity-disorder.html|Slate: Who Wouldn’t Want an Adderall Prescription?]] | ||
| * [[https://newrepublic.com/article/137066/adhd-sold|New Republic: How ADHD Was Sold]] | * [[https://newrepublic.com/article/137066/adhd-sold|New Republic: How ADHD Was Sold]] | ||
| + | * [[https://www.nytimes.com/2020/02/10/well/family/the-marketing-of-stimulants-for-children-with-adhd.html|NYT: The Marketing of Stimulants for Children With A.D.H.D]] | ||
| * [[https://www.psychiatryadvisor.com/adhd/a-true-adhd-epidemic-or-an-epidemic-of-overdiagnosis/article/429034/?check=true|A True ADHD Epidemic or an Epidemic of Overdiagnosis?]] | * [[https://www.psychiatryadvisor.com/adhd/a-true-adhd-epidemic-or-an-epidemic-of-overdiagnosis/article/429034/?check=true|A True ADHD Epidemic or an Epidemic of Overdiagnosis?]] | ||
| * [[https://www.nytimes.com/2016/08/28/books/review/adhd-nation-alan-schwarz.html|Overselling A.D.H.D.: A New Book Exposes Big Pharma’s Role]] | * [[https://www.nytimes.com/2016/08/28/books/review/adhd-nation-alan-schwarz.html|Overselling A.D.H.D.: A New Book Exposes Big Pharma’s Role]] | ||
| * [[http://www.cbc.ca/news/canada/toronto/ontario-children-and-youth-with-adhd-often-prescribed-antipsychotics-study-finds-1.3942049|Ontario children and youth with ADHD often prescribed antipsychotics, study finds]] | * [[http://www.cbc.ca/news/canada/toronto/ontario-children-and-youth-with-adhd-often-prescribed-antipsychotics-study-finds-1.3942049|Ontario children and youth with ADHD often prescribed antipsychotics, study finds]] | ||
| * [[http://www.nytimes.com/2016/10/16/magazine/generation-adderall-addiction.html|NYT: Generation Adderall]] | * [[http://www.nytimes.com/2016/10/16/magazine/generation-adderall-addiction.html|NYT: Generation Adderall]] | ||
| + | * [[https://www.nytimes.com/2019/03/25/smarter-living/why-you-procrastinate-it-has-nothing-to-do-with-self-control.html|NYT: Why You Procrastinate (It Has Nothing to Do With Self-Control)]] | ||
| </WRAP> | </WRAP> | ||
| - | <WRAP quarter column> | + | |
| + | <WRAP third column> | ||
| == Research == | == Research == | ||
| * [[https://jamanetwork.com/journals/jama/fullarticle/2687861|Ra, C. K., Cho, J., Stone, M. D., De La Cerda, J., Goldenson, N. I., Moroney, E., ... & Leventhal, A. M. (2018). Association of digital media use with subsequent symptoms of attention-deficit/hyperactivity disorder among adolescents. JAMA, 320(3), 255-263.]] | * [[https://jamanetwork.com/journals/jama/fullarticle/2687861|Ra, C. K., Cho, J., Stone, M. D., De La Cerda, J., Goldenson, N. I., Moroney, E., ... & Leventhal, A. M. (2018). Association of digital media use with subsequent symptoms of attention-deficit/hyperactivity disorder among adolescents. JAMA, 320(3), 255-263.]] | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||