Management Guidelines for ADHD

Management Guidelines for ADHD ADHD Non-Pharmacological management • • • • • • • • • • • In collaboration with the child, family, carers and teachers Psychoeducation Social and organisation skill training Cognitive training Parent behaviour training Classroom measurement measures - E.g. strategically positioning the child in the classroom, setting rules and expectations and using a daily report card Advice parents or cares of the importance of having close relationships with staff in the child’s school Routine dietary modifications are not recommended to reduce symptoms Do not use dietary supplements unless the child has a deficiency Give family or cares information about relevant support groups and community organisations where they can receive training about managing children with ADHD -> ADHD Australia Other resources that may be useful: - Headspace - Kids helpline - Lifeline Pharmacological Management • Stimulants - First line - Improve attention, decrease impulsiveness and reduce hyperactivity - May also improve general behaviour and interactions with peers and family. - Do not use in children less than 6 unless in exceptional circumstances under close supervision. - There is no evidence that one stimulant is better than the other. - When deciding what to give consider: ➔ Convenience of the once dosing vs multiple daily dosing ➔ The possibility of increased adherence with daily dosing ➔ Any issues with storing a controlled drug at school ➔ The risk of diversion and misuse ➔ The potential to reduce stigma associated with taking medication at school • • • ➔ The pharmacokinetic profile of the formulation, to avoid reduced effect or excessive adverse effects at certain times of the day ➔ Accessibility to PBS - Important points: ➔ Should be considered according to tolerability ➔ More frequent dosing -> giving small additional dose in the mid afternoon ➔ Switching from a short to long-acting formulation ➔ Combining short and long-acting formulations ➔ If symptoms have not significantly improved despite optimising the dosage using the maximum tolerated dose for 1 month -> trial another stimulant Atomoxetine - If stimulants cannot be use, is not tolerated, when there is comorbid Tourette syndrome or a severe anxiety disorder or there is a misuse of stimulants - Given at 0.5 mg/kg Guanfacine - For children who do not tolerate stimulants ot as an adjunct to a stimulant in children with an inadequate response - Useful in children with a comorbid tic disorder e.g. Tourette syndrome - Alpha-adrenergic receptor agonist - 1mg orally at bedtime - Assess patient response after 1 week to determine need for dose adjustment Clonidine - Similar role to guanfacine - Use is limited to short half life ➔ Necessitates multiple daily dosing Monitoring during treatment of ADHD • • Monthly during the early stages of treatment then at least few times a year when stable Things to monitor: - Symptoms - Height and weight - Blood pressure and heart rate - Adverse effects - Comorbid conditions ➔ Including substance abuse - Adherence Duration • Review need for treatment at least once a year - Consider: ➔ Patient preference • • ➔ Adverse effects ➔ Benefits of treatment ➔ Impact of treatment or no treatment on social and other aspects of life Preferably trial should occur at times least disruptive such as school holidays Consider the following: - Stimulants ➔ Can be stopped abruptly ➔ But if the dose is close to or at the maximum dose, gradually reduce the dose - Atomoxetine ➔ Can be stopped abruptly without a gradual reduction - Clonidine ➔ Should be gradually reduced over at least 7 days ➔ Stopping abruptly can cause severe withdrawal symptoms such as: ✓ Rapid rise in blood pressure ✓ Headache ✓ Flushing ✓ Sweating ✓ Insomnia ✓ Agitation ✓ Tremor - Guanfacine ➔ Should be gradually reduced by no more than 1 mg every 3 to 7 days, adverse drug withdrawal effects include an increase in blood pressure