Therapy target
- Improvement of the symptomatology
Treatment planning according to S3 guideline
- “Children with ADHD before the age of six years should receive primary psychosocial (including psychotherapeutic) intervention. Pharmacotherapy for ADHD symptomatology should not be offered before the age of three years.”
- For ADHD with mild severity, primary psychosocial (including psychotherapeutic) intervention should be provided. In individual cases, pharmacotherapy may be offered as a supplement if residual ADHD symptoms require treatment.
- In moderate ADHD, either intensified psychosocial (including intensified psychotherapeutic) intervention or pharmacological treatment or a combination should be offered after comprehensive psychoeducation, depending on the specific conditions of the patient, his or her environment, the preferences of the patient and his or her relevant caregivers, and treatment resources.
- In severe ADHD, pharmacotherapy should be offered primarily after intensive psychoeducation. Parallel intensive psychosocial (including psychotherapeutic) intervention may be integrated into pharmacotherapy. Depending on the course of pharmacotherapy, psychosocial (including psychotherapeutic) interventions should be offered in case of residual ADHD symptoms requiring treatment.
- “For adults with ADHD, treatment should be provided in an overall multimodal therapeutic approach combining psychosocial as well as pharmacological interventions.” A detailed psychoeducation (PE) should be performed before starting treatment! Further psychosocial interventions see below “Further therapy / psychotherapy“.
Therapy recommendations
- For ADHD of mild severity, psychosocial (including psychotherapeutic) intervention should be primary.
- Drug therapy for moderate or severe ADHD [S3 guideline]:
- Stimulants: methylphenidate (MPH; Indirect Sympathomimetics), first-line agent; amphetamines (second-line agent); also lisdexamfetamine (prodrug from the amphetamine substance group), if necessary)Note: A meta-analysis gives preference to methylphenidate in children and amphetamine in adults in terms of efficacy. In children and adolescents, only methylphenidate and modafinil (see “Further notes” below) were found to be more effective than placebo groups; in adults, amphetamines, methylphenidate, bupropion, and atomexetine were found to be more effective than placebo.
- Other active ingredients:
- Atomoxetine (norepinephrine reuptake inhibitor); Indications: Patients with ADHD and coexisting anxiety disorders Stimulants or alternatively choose atomoxetine.
- Guanfacine (alpha 2A receptor agonist); indications: Use in children and adolescents 6 to 17 years of age only when therapy with stimulants such as methylphenidate is not possible, has not been tolerated, and has been shown to be ineffective.
- In addition, tricyclic antidepressants or antipsychotics (neuroleptics) can be used if the above medications are not effective enough
- The FDA notes that there may be an increased risk of suicidality (suicide) when taking the stimulant agent atomoxetine. Relatives should be advised to keep a particularly close eye on patients, especially at the start of therapy. A Swedish study could not find a link between drug therapy for ADHD and increased suicidality (suicide risk).
- Drug treatment with methylphenidate is superior to psychological group therapy in adults. Likewise, it could be shown that the effect of medication could not be improved by an additional group psychotherapy.
- Note: No medication without concomitant psychotherapy/behavioral therapy.
- See also under “Further Therapy.”
Further notes
- Modafinil is a drug used to treat narcolepsy (compulsive daytime sleep seizures); based on case reports, it is suspected that use of modafinil during pregnancy may cause severe congenital malformations.
- The teratogenicity of modafinil was confirmed in a population-based study.Conclusion: no use during pregnancy; contraception (birth control) is necessary, but modafinil may interfere with the effectiveness of oral contraceptives (“the pill”), so alternative or additional safe contraceptive measures are needed.
