Canadian Paediatric Society clinical practice recommendations for children and adolescents with attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a prevalent, pathophysiologically complex and heterogeneous neurodevelopmental disorder originating in childhood and characterized by age inappropriate and impairing levels of inattention and/or hyperactivity/impulsivity hindering development and influencing self-competence in social, academic and behavioural domains. The Canadian Paediatric Society has developed three position statements on ADHD following systematic literature reviews and expert opinion. These position statements are intended to assist primary care providers in implementing diagnosis and treatment guidelines in their management of ADHD in community-based paediatric and family medicine settings. Statement objectives include a summary of the current clinical evidence regarding ADHD, establishing a standard for ADHD care and assisting Canadian clinicians in making well-informed, evidence-based decisions to enhance care of children and youth with this condition. The clinical diagnosis of ADHD is challenging, limited by a lack of reliable diagnostic biomarkers and symptom specificity. The current gold standard for the diagnosis of ADHD is based on subjective reports and observational rating scales from caregivers, teachers, and the patient. Although important assessment tools to document Diagnostic and Statistical Manual of Mental Disorders criteria and to monitor treatment response or side effects, these measures can be problematic; they are open to rater biases, fail to account for the developmental nature of symptoms and the impairment attributable to ADHD, which relates not only to the symptoms but also to the demands of the context in which they manifest. There is an increasing need to find objective markers for the disorder to refine diagnosis, assess the efficacy of the therapies and improve follow-up strategies. In the first position statement, ADHD in children and youth: Etiology, diagnosis and comorbidity, we describe the symptoms, features and impairments associated with this condition and key points of etiology, particularly its strongly heritable nature and the role of neurological, environmental and psychosocial factors in maintaining and exacerbating its impairments. We describe the neuroanatomical and neurophysiological base of this symptom constellation, provide clinical pearls on optimal assessment procedures and on best-practices clinical diagnosis of ADHD. Childhood ADHD is chronic, impairing daily functioning in a wide range of domains, hindering successful positive interaction with peers and influencing quality of life. ADHD often co-occurs with psychiatric and neurodevelopmental disorders hence impacting patient’s symptom trajectories, illness presentation, diagnosis and treatment outcomes. In the second position statement, ADHD in children and youth: Treatment, we provide a summary of the evidence-based treatments for ADHD. Patient and parent choices are an important topic of study with respect to ADHD interventions given the multiple treatment choices available. Since ADHD is often comorbid with other clinical conditions, many patients suffer from secondary problems even after improvement of ADHD core symptoms. Non-pharmacological treatments are often used as adjunct treatment options for symptoms not amenable to treatment. The current guidelines recommend evidence-based behaviour therapy over medication as first line treatment for pre-school age children with ADHD. Our review summarizes the essential elements and evaluates the available evidence for non-pharmacological interventions for children and youth with ADHD. Although the majority of studies focus on medication treatments of ADHD, more research is necessary on the long-term clinical effectiveness of non-pharmacological approaches both as stand-alone interventions and used in combination with medication. Dozens of complementary and alternative treatments have been advocated for ADHD. Most do not have conclusive evidence of effectiveness or safety for ADHD. Pharmacotherapy, including stimulant and non-stimulant medications, is an important part of the ADHD multimodal treatment. Psychostimulants are the most effective therapeutic agents while non-stimulants play an important role options for the management of clinically significant symptoms of ADHD. In the third position statement, ADHD in children and youth: Assessment and treatment with Autism spectrum disorder (ASD), ID or prematurity, we illustrate how ADHD, a heritable neurodevelopmental disorder shows clinical and genetic overlap with other childhood neurodevelopmental disorders. ASD and ADHD are childhood onset neurodevelopmental disorders with overlapping characteristics and etiological factors that may persist into adulthood. The current DSM-5 diagnostic criteria allow co-diagnosis of ASD and ADHD. Children with intellectual deficiency and those born pre-term are at increased risk for ADHD symptoms. Despite the increasing prevalence of these populations, there is a scarcity of research looking at how these disorders co-occur with ADHD. There is a need for long-term follow-up studies of the safety and efficacy of medications for those with ADHD with comorbidities and in special populations. Paediatricians and family physicians are often the first point of contact for families of children and youth suffering from ADHD and comorbidities. The majority of patients with these conditions are diagnosed and treated in community clinics. Residency training programs for paediatricians and family physicians must incorporate behavioural, developmental and mental health training including ADHD diagnosis and treatment among its explicit learning objectives and take measures to ensure this objective is being met. Funding: There are no funders to report for this submission. The authors reported no conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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