Goal-setting & re-assessment
Attention-deficit hyperactivity disorder (ADHD), or hyperkinetic disorder (HKD), is a heterogeneous disorder, and the degree of impairment experienced by individual patients varies depending on personal circumstances.1 Similarly, not all patients respond to treatments in the same way. Therefore, following accurate assessment and diagnosis it is important to adopt a patient-centred management approach to identify the needs of the patient and family, agree treatment goals, develop a tailored treatment plan, re-assess and evaluate treatment response, and ensure goals are regularly updated to reflect changed circumstances and needs (Figure).1-3
Patient-centred management approach in ADHD.1-3
Identifying the needs of the patient and family
When making diagnostic decisions and selecting appropriate treatment options, it is important to fully understand the impact that symptoms of ADHD have on a patient’s functioning and quality of life.4 An analysis of the relationship between ADHD symptoms, quality of life and functional impairment in adults with ADHD found that single ADHD symptoms could manifest as multiple problem behaviours which, combined in complex ways, impact on several aspects of a patient’s life.5 Patients also reported difficulties with productivity; the functional impact varied depending on the employment status and type of work (detail-oriented work was more negatively affected).5
Agreeing treatment goals
Since the impact of ADHD varies between individuals, specific treatment goals should be developed to adequately address the needs of each patient.1,6 Functional impairments typically underlie the referral to clinical services, and should be considered along with behavioural symptoms in setting appropriate treatment goals.7 The degree and types of functional impairments are influenced by a variety of internal (e.g. comorbidities, age, and ADHD subtype) and external factors (e.g. family situation and employment status).5,8
Examples of functional impairments and appropriate goals across age groups
|Functional impairment||Examples of appropriate goals|
|Children with ADHD are significantly more likely to display poor academic performance, such as difficulties with reading, writing and mathematics compared with children without ADHD.9||Neater handwriting or reading a chapter of a book could be achievable small goals.|
|Adolescents with a history of ADHD tend to experience greater peer rejection and have fewer close friendships than their non-ADHD peers. This may over time spiral into restriction in social activities, additional relationship problems and internalised distress.10||Improving social skills, being invited to social events, or attending structured after-school activities may be valuable.|
|Many young adults with ADHD exhibit impaired driving performance,11 characterised by more risky, impulsive and distracted behaviours while driving, compared with peers without ADHD.12||Improvements in driving performance (e.g. fewer vehicular accidents and traffic citations).|
|Adults with ADHD can experience functional impairments across diverse aspects of daily life, including employment-related issues, legal problems, addictive behaviours and relationship problems.13,14||Working with an employer to set relevant short-term job-related objectives and discussing ADHD with employer and colleagues/HR/occupational support.|
Individualising a management plan
A systematic review of the guidelines found that the majority agreed on the need for particular forms of psychosocial intervention including psychoeducation, individual educational programmes with appropriate adaption as required. However, the review also found that psychostimulants were generally the first-line pharmacological treatment option recommended.15 The large-scale MTA study, which examined the long-term effectiveness of pharmacotherapy and behavioural interventions alone and in combination, demonstrated that a multimodal approach, ie a combination of behavioural treatment and pharmacotherapy management, was the best approach to the treatment of ADHD.16
Several factors may need to be considered when developing a multimodal treatment plan:1,3,17-19
- Patient-specific characteristics (such as age, ADHD subtype, comorbidities)
- Personal preference of patients and their parents or partner
- Type of medication (stimulant or non-stimulant)
- Formulation of ADHD medication (such as the need for flexibility; coverage throughout the day; compliance needs or ability to swallow).
Evaluating treatment goals
It is important to periodically re-evaluate the alignment of treatment goals to the current needs of the patient. Patients’ needs will change as they progress through the different stages of life and the impact of the disease will also vary depending on response to therapy.20-22 It is important to involve the patient, family, partner and teachers in the re-assessment and re-development of goals and treatment plans.1,3,17-19 Parental support has been identified as a key component of successful transitions from child and adolescent to adult mental health services in the UK.23
Multidisciplinary team approach to managing individuals with ADHD in The Netherlands – clinician insight
“In The Netherlands, multidisciplinary teams work together to implement a multimodal treatment plan:
- Psychologists administer and supervise psychosocial interventions
- Child psychiatrists and paediatricians bear responsibility for pharmacological treatment choices and can prescribe medication
- If any issues arise with the individual with ADHD, joint appointments between psychologists and psychiatrists/paediatricians may be carried out so that adjustments to psychosocial interventions and medication can be discussed in parallel.
Schools may also be involved in the management of children/adolescents with ADHD:
- School personnel may receive training/education about ADHD, allowing them to implement certain interventions.
Furthermore, families receive support in the home where needed.
Both schools and family members can contribute to long-term monitoring of the child/adolescent with ADHD.”
Information kindly provided by Dr Gracita Ramnath, Spaarne Hospital, The Netherlands.
April 2016; job code: INTSP/C-ANPROM/NBU/16/0014
- NICE (2008) Attention Deficit Hyperactivity Disorder: Diagnosis and Management of ADHD in Children, Young People and Adults. NICE clinical guideline 72. Available at www.nice.org.uk/CG72 [NICE guideline]. Last accessed May 2015.
- Sibley MH, Pelham WE Jr., Molina BS, et al. Diagnosing ADHD in adolescence. J Consult Clin Psychol 2012; 80: 139-150.
- Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder – first upgrade. Eur Child Adolesc Psychiatry 2004; 13 Suppl 1: i7-i30.
- Kovshoff H, Williams S, Vrijens M, et al. The decisions regarding ADHD management (DRAMa) study: uncertainties and complexities in assessment, diagnosis and treatment, from the clinician's point of view. Eur Child Adolesc Psychiatry. 2012; 21: 87-99.
- Brod M, Pohlman B, Lasser R, et al. Comparison of the burden of illness for adults with ADHD across seven countries: a qualitative study. Health Qual Life Outcomes 2012; 10: 47.
- Hodgkins P, Dittmann RW, Sorooshian S, et al. Individual treatment response in attention-deficit/hyperactivity disorder: broadening perspectives and improving assessments. Expert Rev Neurother 2013; 13: 425-433.
- Pelham WE Jr., Fabiano GA, Massetti GM. Evidence-based assessment of attention deficit hyperactivity disorder in children and adolescents. J Clin Child Adolesc Psychol 2005; 34: 449-476.
- Booster GD, Dupaul GJ, Eiraldi R, et al. Functional impairments in children with ADHD: unique effects of age and comorbid status. J Atten Disord 2012; 16: 179-189.
- Holmberg K. Adolescent Academic Outcome of Childhood Attention-Deficit/Hyperactivity Disorder – A Population-Based Study in: Norvilitis JM, ed. Contemporary Trends in ADHD Research. InTech, 2012: 87-106.
- Mrug S, Molina BS, Hoza B, et al. Peer rejection and friendships in children with attention-deficit/hyperactivity disorder: contributions to long-term outcomes. J Abnorm Child Psychol 2012; 40: 1013-1026.
- Barkley RA, Murphy KR, Dupaul GI, et al. Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning. J Int Neuropsychol Soc 2002; 8: 655-672.
- Merkel RL Jr., Nichols JQ, Fellers JC, et al. Comparison of on-road driving between young adults with and without ADHD. J Atten Disord 2012. Feb 11 [Epub ahead of print].
- Adamou M, Arif M, Asherson P, et al. Occupational issues of adults with ADHD. BMC Psychiatry 2013; 13: 59.
- Biederman J, Faraone SV, Spencer TJ, et al. Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community. J Clin Psychiatry 2006; 67: 524-540.
- Seixas M, Weiss M, Müller U. Systematic review of national and international guidelines on attention-deficit hyperactivity disorder. J Psychopharmacol 2012; 26: 753-765.
- The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperacitivity disorder. Arch Gen Psychiatry 1999, 56: 1073-1086.
- Kooij SJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 2010; 10: 67.
- Harpin VA. The effect of ADHD on the life of an individual, their family, and community from preschool to adult life.Arch Dis Child. 2005 Feb;90 Suppl 1:i2-7.
- The Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines (CAP-Guidelines) Third Edition. 2011. Last accessed April 2015.
- Hurtig T, Ebeling H, Taanila A, et al. ADHD symptoms and subtypes: relationship between childhood and adolescent symptoms. J Am Acad Child Adolesc Psychiatry 2007; 46: 1605-1613.
- Martel MM, von Eye A, Nigg J. Developmental differences in structure of attention-deficit/hyperactivity disorder (ADHD) between childhood and adulthood. Int J Behav Dev 2012; 36: 279-292.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2004.
- Swift KD, Hall CL, Marimuttu V, et al. Transition to adult mental health services for young people with attention deficit/hyperactivity disorder (ADHD): a qualitative analysis of their experiences. BMC Psychiatry 2013; 13: 74.
Registration gives the benefit of full access to the high-value content and regular site update emails.
NEW Childhood/adolescent ADHD and treatment effects in the brain. By Dr Mitul Mehta
New eLearning Module on the treatment of Child, Adolescent and Adult ADHD, is now available.
Patient-centred management: every patient is different with unique needs – a Spanish perspective. Part 2: Treatment plans
Patient-centred management: every patient is different with unique needs – a Spanish perspective