ADHD treatment and support - Australian ADHD Clinical Practice Guideline

3. Treatment and Support

3.1 Multimodal treatment and support

Clinical Questions

1. Which factors need to be considered when making initial treatment decisions for ADHD?
2. How should ADHD symptom severity and clinical profile guide treatment decisions?
3. Does the optimal treatment approach for ADHD vary when co-occurring disorders are present?
4. What is/are the most clinically effective initial sequence(s) of pharmacological/non-pharmacological treatment for people with ADHD?

Clinical practice gaps, uncertainties and need for guidance

After a diagnosis of ADHD, the person and their clinician need to decide which treatment options are most appropriate and the order in which these should be initiated and/or trialled.

Key principles underpin treatment decisions (see Principles and Assumptions):

People with ADHD should be involved in making decisions about their own care, as appropriate to their age and developmental stage.
The clinician should fully inform the person about the options for care, the benefits and possible adverse effects of each.
The acceptability and feasibility of each treatment for each person (dependent on age, location, resources, and service capacity) should be considered.

Summary of evidence review

Evidence reviews conducted for these questions identified no new evidence. NICE reviewed the evidence available to compare non-pharmacological and pharmacological strategies’ effectiveness. The review included a wide range of potential outcomes, including adverse events.

The quality of evidence was low or very low. Most evidence evaluated treatments in children and adolescents aged 5–17 years. No evidence was identified that compared outcomes for different treatment modes in children aged 5 years. The NICE reviewers noted that comparisons were sometimes difficult due to the variety of outcomes assessed and methodological differences between trials. No comparison between any two combined treatments clearly showed a consistent, clinically important benefit of one option over another.

Overall, the NICE evidence review found that pharmacological treatment was more effective than non-pharmacological treatment in reducing core ADHD symptoms. Combined pharmacological and non-pharmacological treatment was better than either alone. Each mode was more effective than the other in targeting specific aspects of ADHD: pharmacological treatments were more effective for reducing core ADHD symptoms, and non-pharmacological treatments were more effective for improving functional outcomes for people with ADHD, see Box 3.

There is currently no evidence from which to ascertain whether it is generally more effective to start treatment with pharmacological approaches or non-pharmacological approaches, or the optimal time to start treatment. In the absence of direct evidence, these decisions should consider availability, cost, preferences and potential harms.

Box 3. Main targets for pharmacological and non-pharmacological treatment

Pharmacological treatment

Primary outcome: symptom reduction
Secondary outcomes: improved functioning and wellbeing

Non-Pharmacological treatment

Primary outcome: improved functioning and wellbeing
Secondary outcomes: symptom reduction

Summary of narrative review

Initial treatment decisions and sequence

Recommendation for the use of combined pharmacological and non-pharmacological treatments are based on the balance of availability, costs, preferences, values assigned to consequences and resulting judgements. Non-pharmacological treatments can be combined with medication. If medication is not effective enough, non-pharmacological treatments can be added to the treatment plan. Alternatively, if non-pharmacological approaches are tried first, and functional impairment remains, medication can be added.

Combined treatment has the advantage of addressing multiple facets of ADHD, as non-pharmacological treatments and pharmacological treatments have different targets, as noted in Box 3. Current evidence best supports the use of pharmacological treatments for treating the core symptoms of ADHD and suggests non-pharmacological treatments may be more beneficial for improving the function of people with ADHD. Treatment for commonly co-occurring conditions, such as affect dysregulation, anxiety, and low mood, should be included as part of a treatment plan and follow best-practice guidelines for each co-occurring condition, as noted in section 2.2.

Treating health professionals should consider combined treatment:

if it is available, feasible and cost-effective for the person and in the local context, and the available treatment is appropriate for symptoms, function or participation needs
in people who experience an inadequate response to pharmacological or non-pharmacological treatment alone.

These decisions should consider potential adverse effects and costs, both direct and indirect. Treatment effects should be monitored for effectiveness, including treatment-specific outcomes and adverse effects. Timing of the effect of intervention may also be a factor, given stimulant medication works immediately, whereas some non-stimulant medications may take several weeks to have an effect, and similarly for non-pharmacological treatments.

These recommendations are based on the current evidence, which indicates that combined treatments are more effective in treating ADHD symptoms than either pharmacological treatment or non-pharmacological treatment in isolation and that this benefit is larger and more consistently observed when compared with non-pharmacological treatment.

Impact of symptom severity and co-occurring conditions on treatment

Research on ADHD symptom severity and treatment is extremely limited. Multimodal treatment allows for a tailored approach. The clinical profile may guide treatment decisions. For example, non-stimulant medications may be indicated for a person with co-occurring Tourette syndrome.

In addition to discussing the severity of symptoms, degree of impairment, and individual and family views of treatment options, the clinician should explain all the available treatment options and the benefits and harms of each. Treatment decisions should also consider the person’s medical conditions (for example, cardiovascular disease) and medication safety during pregnancy and breastfeeding.

See section 5.2 for further information managing co-occurring disorders.

Care integration and coordination

ADHD treatment and support require a multimodal, multidisciplinary and multi-agency approach, particularly when there are co-occurring conditions that significantly impact a person’s functioning and quality of life (Coghill, 2017). Where multiple clinicians, professionals and services are involved in the treatment and support of a person with ADHD, a care coordinator can be employed or nominated. This role is usually performed by a clinician in the support team. Sometimes this role can be performed by an adult with ADHD themselves or by the carer of a child with ADHD if they prefer.

Ideal models of care are integrated and transdisciplinary, whereby professionals from multiple agencies collaborate with each other, and the person and/or child and family with ADHD, to form a team. This care team should, from the beginning, allow sharing and integration of expertise into a single treatment plan (Bell, Corfield, Davies, & Richardson, 2010; Miller & Eastwood, 2016). The care coordinator should advocate for the preferences and needs of the person with ADHD so that a shared care decision-making model is adopted for treatment planning (Davis, Claudius, Palinkas, Wong, & Leslie, 2012).

Evidence-to-recommendation statement

Factors to be considered when making treatment decisions addressed by NICE have been adapted for the Australian context. Regarding the sequence of treatments, NICE noted there were many comparisons showing no clinical difference and relatively frequent inconsistencies across the evidence base. The NICE review noted that broader outcomes, reflecting improvement in daily life, were less commonly reported in studies than symptom outcomes.

This imbalance is important because non-pharmacological interventions often target outcomes that go beyond the symptoms of ADHD as noted above. The review also noted that it was more difficult to include a caregiver-blinded or person-blinded control group for non-pharmacological intervention studies than for pharmacological studies and that this difference in study design makes it difficult to reach an unbiased overall interpretation of the relative effectiveness of non-pharmacological treatments.

Given these considerations, the NICE committee concluded that there was insufficient evidence to make strong recommendations about any sequence or combinations of treatments. It is also important to note that ADHD medications will not provide full coverage over the course of a day/evening. Non-pharmacological therapy can assist with the development of strategies and skills to maximise functioning at such times.

Given the lack of evidence regarding combined treatment, we suggest a multimodal treatment and support approach, which could include pharmacological and/or non-pharmacological treatments either alone or in combination, with some considerations provided regarding the order of treatment. We suggest that treatment order and combination are decided individually based on the person’s needs and preferences.

Recommendations

Clinical considerations for implementation of the recommendations

The ability to offer non-pharmacological interventions may be limited by cost and clinician availability, which may be influenced by geographical region. Some medications used to treat ADHD are not available on the Pharmaceutical Benefits Scheme (PBS) for some people with ADHD, so cost may reduce accessibility for some people. Non-pharmacological treatments may also vary in regard to optimal timing, frequency and duration of sessions needed, with cost implications.

Usual care in Australia often involves care coordination by an individual, either formally or informally. In contexts where this is not occurring, ensuring the availability of people to fulfil this role may incur additional costs and resources. For example, care coordinators may be less likely to be involved in the care of adults with ADHD.

See Technical Report, sections 6.1, 6.4, and 6.5 for further details