ADHD Management Across the Lifespan

ADHD is a persistent disorder with functional impairment and treatment needs varying through the lifespan, for many. It is important, therefore, for clinicians to be aware of these differences, and the various management options, so as to better serve individuals with ADHD.

Drug treatments include both stimulant and non-stimulant medications. Typically, more effective management is achieved through a combination of approaches. National guidelines include comprehensive recommendations for the management of ADHD in children, young people, and adults. A brief summary is provided here. Healthcare professionals should also refer to the complete guideline, NG 87.⁵

For children under 5 years old:

An ADHD-focused, group parent-training programme should be offered to parents or carers as first-line treatment. If ADHD symptoms across settings are still causing significant impairment, after environmental modifications have been implemented and reviewed, obtain advice from a specialist ADHD service with expertise in managing ADHD in young children (ideally a tertiary service). Medication should not be offered without a second specialist opinion from an ADHD service with expertise in managing ADHD in young children.

For children aged 5 years and over, and young people:

Give information about ADHD and offer additional support to parents and carers. The support should be ADHD focused, can be group-based and as few as 1 or 2 sessions and should include education and information on the causes and impact of ADHD, advice on parenting strategies, liaison with school, college, or university (with consent). If there are also symptoms of oppositional defiant disorder or conduct disorder, offer parents and carers a parent-training programme, as well as group-based ADHD-focused support. Medication should only be offered if ADHD symptoms are still causing a persistent, significant impairment in at least one domain, after environmental modifications have been implemented and reviewed, after the individual and their parents and carers have discussed information about ADHD and after a baseline assessment has been carried out. 
A course of Cognitive Behavioural Therapy (CBT) should be considered for young people with ADHD who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain.

Medication should only be initiated by healthcare professionals with training and expertise in diagnosing and managing ADHD. For children aged 5 years and over and young people with ADHD, methylphenidate (either short or long acting) should be offered as the first line pharmacological treatment. Consider switching to lisdexamfetamine for those who have had a 6 week trial of methylphenidate, at an adequate dose, and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment. Consider dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile. Offer atomoxetine or guanfacine to those who cannot tolerate methylphenidate or lisdexamfetamine or those whose symptoms have not responded to separate 6 week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses. Note: Methylphenidate is first-line pharmacological treatment for children aged 5 years and over and young people with ADHD. However, no formulation of methylphenidate is licensed for use in children under 6 years of age. Use in children aged 5 years (or under) is, therefore, off-label.

For Adults with ADHD:

They should be offered medication if their ADHD symptoms are still causing significant impairment in at least one domain after environmental modifications have been implemented and reviewed. Non-pharmacological treatment should be considered for adults with ADHD who have made an informed choice not to have medication and/or have difficulty adhering to medication and/or who have found medication to be ineffective or cannot tolerate it. A combination of non-pharmacological treatment and medication should be considered for those who have benefited from medication but whose symptoms are still causing a significant impairment in at least one domain.

Medication should only be initiated by healthcare professionals with training and expertise in diagosing and managing ADHD. What pharmacological treatments should you consider?

Methylphenidate or lisdexamfetamine should be offered as first-line pharmacological treatment for adults with ADHD. Consider switching to lisdexamfetamine for adults who have had a 6-week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms 
of reduced ADHD symptoms and associated impairment. Consider switching to methylphenidate for adults who have had a 6-week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment. Consider dexamfetamine for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile. Atomoxetine should be offered to adults if they cannot tolerate lisdexamfetamine or methylphenidate or if their symptoms have not responded 
to separate 6 week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Note: Methylphenidate is co-first-line treatment for adults with ADHD. However, not all formulations of methylphenidate are licensed for use
in adults. It is recommended that prescribers consult the product Summary of Product Characteristics before initiating treatment with methylphenidate.