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.