First evidence-based guidelines for ADHD

The practice guide identifies at-risk and underdiagnosed groups and sets out when to screen and how to treat.

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Australia’s first evidence-based clinical practice guidelines for attention-deficit/hyperactivity disorder are out, covering everything from identification of high-risk groups to professional training for those working with children and adults with the condition.

The NHMRC-endorsed guidelines – the work of the Australian ADHD Professionals Association (AADPA) – are long overdue, AADPA president and cognitive neuroscientist Professor Mark Bellgrove told The Medical Republic.

“It’s really important that, for a condition that affects around a million people in Australia, we have a unified bible with respect to diagnosis, treatment and support for folks with ADHD,” said Professor Bellgrove, also director of research at the Turner Institute for Brain and Mental Health at Monash University.

The most evidence-based recommendations in the guidelines are around identification of groups with a higher prevalence of ADHD, which has a strong genetic component. These high-risk groups include people of all ages already diagnosed with neurodevelopmental disorders including autism spectrum disorder and language and learning disorders; those with anxiety, depressive or bipolar and related disorders; those who have been in prison; and those with a close family member with the condition.

Children who are in out-of-home care or have been diagnosed with oppositional defiant disorder or conduct disorder, or with anxiety disorder, and adults with any mental health disorder, are also considered high-risk.

“We certainly don’t advocate for universal screening at the population level, but what we do say is that there are high-risk groups where you should be on the lookout for ADHD,” Professor Bellgrove said. This includes all age groups, even those over 65.

The guidelines also highlighted that ADHD may be underdiagnosed and undertreated in women and girls, saying they are less likely to be referred for assessment and more likely to receive an incorrect diagnosis.

The recommendation is that clinicians screen for ADHD when conducting a mental health or psychiatric diagnostic assessment on someone from a high-risk group, particularly if that person is not responding to treatment for their existing condition, shows signs of ADHD symptoms such as missing appointments, restlessness and fidgeting, disorganisation and distraction.

However, diagnostic assessments should be done by a clinician with experience in doing ADHD assessments, and the assessment should include discussion of how the symptoms affect different domains of the person’s life, observer reports of that person’s symptoms and mental state, and a full developmental, mental health and medical history.

The guidelines point out that symptom questionnaires and other screening and assessment tools may not be valid in Aboriginal and Torres Strait Islander people. If the person being assessed is of Aboriginal or Torres Strait Islander origin, the authors recommend getting assistance from a cultural interpreter or Aboriginal and Torres Strait Islander health worker.

Another strong recommendation is that the parents and families of children and adolescents should be offered parent/family training, especially if the adolescents also have oppositional defiant disorder or conduct disorder.

“Clinicians should explain to parents and carers that a recommendation of parent/family training is to optimise parenting skills to meet the additional parenting needs of children and adolescents with ADHD, and does not imply bad parenting,” the guidelines authors wrote.

On the question of treatment, the guidelines committee identified significant evidence – albeit of low quality – to support both cognitive-behavioural interventions and pharmacological treatment such as methylphenidate (Ritalin), dexamfetamine or lisdexamfetamine in those experiencing significant impairment from the condition.

Professor Bellgrove said the evidence suggested around 70%-80% of children and adults with ADHD will experience a reduction in symptoms and improved functioning with medication.

“There are a portion that are classed as non-responders, in which case they might be trialled on another type of medication,” he said, with the guidelines suggesting atomoxetine or guanfacine as second-line options for both children and adults.

The guideline authors also called for funding of a national ADHD helpline, which currently operates without government support, and that people with ADHD have access to the National Disability Insurance Scheme.

“Eligibility and access to support from the NDIS should be decided based on the functional needs of the person with ADHD, and not based solely on diagnosis,” the authors wrote.

Professor Bellgrove pointed out that ADHD cost an estimated $20 billion per year in Australia. “ADHD is a highly treatable condition and if we can … help people live well and productive lives, the benefit for the social and economic fabric of Australia is enormous.”