By Robert Walton
In this blog for anyone affected by ADHD, Robert Walton, a GP and Senior Fellow in General Practice at Cochrane UK, examines the latest Cochrane evidence on the best ways of managing the condition and some things you may want to consider when making treatment choices.
Take home points
It’s a diagnosis that sometimes creeps up on you. Parents may have thought for some time that their child was more easily distracted than other children, with a short attention span and always forgetful and losing things.
School reports each year may seem predictable – highlighting mistakes, messy work and poor handwriting. In some children, symptoms are confined to inattentive behaviour but for most with ADHD, there will also be symptoms of impulsiveness, constant fidgeting, interrupting other people’s conversations and talking excessively. Sometimes this behaviour may be labelled by the school as ‘disruptive’. Then the penny drops. A trip to the GP may confirm that a diagnosis of ADHD is likely and a round of specialist assessments then follows – unfortunately at a pretty slow pace in the current NHS. Many private clinics have sprung up to fill the gap, but the quality of advice on diagnosis and treatment may be variable.
For adults, the penny may have taken longer to drop. When it does there may be a feeling of relief when a wide range of symptoms – perhaps previously thought to be due to anxiety or depression – come together under this one banner and finally start to make sense. Or it may be something that is difficult to come to terms with, highlighting the need for extra support. The symptoms are persistent throughout life and will have been there since childhood. Growing older the hyperactivity tends to disappear, but the inattentive cluster of symptoms persists, often interfering with work and social activities.
There is much attention in the media at present about negative aspects of ADHD but there is a positive side too – creativity, spontaneity, energy and resilience may also be part of the picture. It’s important not to forget this!
Nonetheless, people generally want to find ways to help them to manage the condition. So, what is there in the way of treatment to help the increasing number of people diagnosed with ADHD? What might you want to consider when looking at treatment options?
Management choices
Successfully managing symptoms of ADHD generally involves constructing a flexible plan with different components involving social and environmental changes, coupled with psychological and drug therapy if needed. Different components of the plan will have different weights at each stage of a person’s life. Developing a good understanding of different aspects of the condition and working out ways around the challenges that it brings is fundamental to effective symptom management. Many resources are available to help with this by providing information and support.
Solutions to address specific problems are likely to be different for different people at different times, but people may benefit from very simple changes to everyday routines. Examples might be changing your environment to reduce distractions when necessary, or starting to use a diary and to-do list. If specific treatments are needed then there are several options, each of which could be a part of the overall management plan according to personal preference. (You may like to read this blog ‘Making health decisions: things that can help’).
Drug treatment for ADHD
Perhaps the first thought for patients, parents and doctors is “What medication can I use that might help?”.
Methylphenidate
Of the medicines prescribed for people with ADHD, methylphenidate is the most commonly used. It can be taken either as immediate-release or slow (extended)-release preparations.
Methylphenidate for children with ADHD
A recent Cochrane Review on Methylphenidate for children and adolescents with ADHD (published April 2023) casts some doubt on the use of methylphenidate.
As a GP, I have seen some remarkable results when children have started medication. However, this Cochrane Review summarises 212 individual trials of slow-release methylphenidate – which is the most commonly used drug in this age group – and all the evidence of harms and benefits was very low certainty. This means that we can’t be sure about the effects or side effects of treatment. One explanation for the apparent discrepancy may be that some children respond and some do not and it is not possible at the moment to identify in advance which group your child will fall into. So in routine clinical practice, methylphenidate is often tried first and then changed to a different drug if it is not working very well. This personalised approach to management is difficult to test in conventional clinical trials.
Methylphenidate for adults with ADHD
In recent years there has been a tendency to move towards slow or extended-release versions of methylphenidate rather than the immediate-release preparations that were initially available. The idea behind this is that the side effects – particularly disordered sleep, drowsiness and palpitations – might be related to the levels of the drug and could be avoided if the absorption of methylphenidate were slowed down.
A Cochrane Review on Immediate‐release methylphenidate for ADHD in adults (published January 2021) compared the older versions of the drug with placebo. The evidence was very low-certainty but suggested that immediate-release preparations may have little benefit and may increase the risk of unwanted effects such as loss of appetite, dry mouth, nausea, and stomach aches. Again, we can’t be sure of the true effects of this treatment without better evidence.
A Cochrane Review looking at the effects of extended-release methylphenidate for ADHD in adults (published February 2022) found evidence of very low certainty, meaning that no certain conclusions could be reached about the benefits and harms of this treatment.
People with ADHD sometimes work out with their clinician that a combination of regular slow-release methylphenidate with supplementary immediate release suits them best. The supplementary immediate release may be taken as needed or regularly at a particular time of the day. We don’t have Cochrane evidence on this tailored strategy and it would be difficult to test properly in a clinical trial.
Amphetamines for adults with ADHD
Drugs other than methylphenidate are sometimes used. Amphetamines are the commonest group, and they are usually only given to adults. A Cochrane Review on Amphetamines for ADHD in adults (published August 2018) found that there may be a benefit from treatment but the evidence supporting this idea is generally low- or very low certainty and comes from only a few very small studies.
Is there a better approach to managing ADHD symptoms?
Cognitive-behavioural therapy for adults with ADHD
Well, the ‘cure-all’ treatment of the modern age is cognitive behavioural therapy (CBT) and a Cochrane Review examined the effects of CBT in adults with ADHD (published March 2018). Here we find that this treatment probably reduces self-reported ADHD symptoms and to a substantial degree. The findings are based on five randomised controlled trials with 251 participants where people were either called for treatment or left on a waiting list. But the findings were less certain when the reviewers compared people having cognitive behavioural therapy to those just having general supportive therapy.
Unfortunately, access to specialised cognitive behavioural therapy for ADHD is patchy in the NHS and it may be difficult to judge the quality of private providers. However general supportive therapies and CBT are available by self-referral without the need to see a GP. These services are not set up to deal with ADHD specifically but can nevertheless be a great help.
Social skills training for children with ADHD
Another Cochrane Review found that social skills training in children with ADHD may improve teacher- and parent-rated behaviour (published June 2019) and it may be that the skills training included an element of behavioural therapy aimed at boosting these specific skills.
Unfortunately, there are no self-referral psychological services for children in the NHS so access to these therapies is usually through the GP and subsequent referral to the Child and Adolescent Mental Health Services.
Unanswered questions about managing ADHD
Research papers sometimes end by saying how important it is that more studies are conducted, and I often wonder whether this statement is justified. But in this case, surely researchers are correct to ask for more studies given the poor quality of evidence so far, the public interest in the condition at present, and the potential benefits that might be gained for individuals and society as a whole.
As a doctor, it is hard to dismiss the evidence of one’s own eyes seeing adults and children in clinic who are treated for ADHD with both psychological and drug treatments and who appear to derive considerable benefit. One wonders whether people with certain characteristics will respond when others do not. The challenge for the future may be to work out who benefits most from which treatment approach and in what circumstances.
References (pdf)
You can join in the conversation on Twitter with @CochraneUK @rtwalton123 or leave a comment on the blog.
Please note, we cannot give specific medical advice and do not publish comments that link to individual pages requesting donations or to commercial sites, or appear to endorse commercial products. We welcome diverse views and encourage discussion but we ask that comments are respectful and reserve the right to not publish any we consider offensive. Cochrane UK does not fact-check – or endorse – readers’ comments, including any treatments mentioned.
ABOUT ROBERT WALTON
Robert Walton is a Cochrane UK Senior Fellow in General Practice. Robert qualified in medicine in London in 1983, having taken an intercalated degree in human pharmacology and immunology. He trained at St Georges Hospital, London and became a member of the Royal College of Physicians in 1986. His work applying computerised decision support to prescribing drugs in the Department of Public Health and Primary care in Oxford led to a doctoral thesis in 1998. Robert was elected a Fellow of the Royal College of General Practitioners in 1999 and the Royal College of Physicians in 2001. He became a Senior Investigator in the National Institute for Health Research (NIHR) in 2016. Robert is Clinical Professor of Primary Medical Care at Queen Mary and was joint lead of the NIHR Research Design Service east London team. His research interests are in primary care, genetics, clinical trials and personalised medicine. Robert led a five-year NIHR funded programme developing a novel training intervention to promote smoking cessation in pharmacies in east London which included a substantive Cochrane review and meta analysis on behaviour change interventions in community pharmacies and a large scale cluster-randomised clinical trial. His research team is also developing a smartphone game to promote smoking cessation and researching a personalised/stratified medicine approach to tobacco dependence using computerised decision support. He sat on the NIHR Programme Grants for Applied Research sub panel A and worked as an evaluator for the European Union Horizon 2020 programmes Global Alliance for Chronic Diseases and New Therapies for Rare Diseases and as a monitor for EU projects. Robert contributes to UK national guidance, and has served on the National Institute for Health and Care Excellence (NICE) Outcome Indicator and Technology Appraisals Committees.
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This post was previously published on evidentlycochrane.net and is republished here under a Creative Commons license.
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The post ADHD: Evidence to Help You Decide How Best to Manage the Condition appeared first on The Good Men Project.
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