Attention Deficit Hyperactivity Disorder (ADHD)

Introduction

Attention deficit hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder consisting of a pattern of inattention and/or hyperactivity-impulsivity more frequent and severe than typically observed in individuals of comparable developmental level.

Hyperactive and impulsive symptoms tend to decrease with age.

  • 50-70% patients continue to have significant inattentiveness, restlessness and impulsivity.



Management

Combination of pharmacotherapy and behavioural therapy is more beneficial than either intervention alone.

  • For preschool children (age 4 through 5 years) who meet the diagnostic criteria for ADHD, behaviour therapy is recommended by American Academy of Paediatrics rather than medication as the initial therapy.

Routine dietary modification is not indicated to reduce symptoms of ADHD because only a minority of children are sensitive to the effects of synthetic dyes, flavours and preservatives.

  • Use of a food diary can be beneficial to link symptoms to dietary exposures.



Medications

Stimulant medications

  • Highly effective for most children in reducing core symptoms of ADHD.
  • Some children with ADHD respond better to one stimulant type than another; therefore, both methylphenidate- and amphetamine-containing products should be tried before stimulant treatment is deemed a failure.
  • No established evidence of causative relationship between stimulants and sudden cardiac death.

Non-stimulant medications - 2nd-line treatment for ADHD; usually used if stimulant medication ineffective or poorly tolerated.

  • Norepinephrine reuptake inhibitors (e.g. Atomoxetine)
    • May be first choice in children with active substance abuse problem, comorbid anxiety or tics.
    • Monitor closely for development of suicidal thoughts and behaviours.
  • Alpha-adrenergic receptor agonists (e.g. Clonidine extended release and Guanfacine extended release)
    • May be used as monotherapy or adjunct to stimulants.
    • Improves comorbid tic disorder.
  • Antidepressants (off-label)
    • Bupropion, TCA antidepressants (e.g. imipramine, nortriptyline)



Supplements

Omega-3 fatty acid supplementation, such as 300-600 mg/day of omega-3 and 30-60 mg/day of omega-6, may be associated with small improvement in symptoms of ADHD in children.



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