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If monetary compensation is involved, you must provide notice to CADDRA at least ten (10) business days before the presentation and request permission. Modification of the Materials or use of the Materials for any other purpose, without the prior written consent of CADDRA, is a violation of CADDRA's copyright and other proprietary rights. CADDRA Information Current contact details for the Canadian ADHD Resource Alliance (CADDRA) and information on ordering copies of the Canadian ADHD Practice Guidelines are available on the CADDRA website: www.caddra.ca Guidelines Citation The correct citation for this document is: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018. French Edition This document is available in French under the title: Lignes directrices canadiennes pour le TDAH, quatrième édition. Feedback Reader suggestions can be provided through our website (www.caddra.ca) or by emailing [email protected]. Liability While great effort has been taken to assure the accuracy of the information, the Guidelines Committee, CADDRA and its members, designer, printer and others contributing to the preparation of his document cannot accept liability for errors, omissions or any consequences arising from the use of the information. Since this document is not intended to replace other prescribing information, physicians are urged to consult the manufacturers' product monograph and other available drug information literature before prescribing. Please Note: The CADDRA website (www.caddra.ca) will always have the latest version of the Guidelines available free to download and print. ISBN: 978-0-9738168-4-6 © 2018 Canadian ADHD Resource Alliance (CADDRA) TABLE OF CONTENTS INDEX OF TABLES AND FIGURES / USB CONTENTS ........................................................................................................... i GUIDELINES EDITORS AND CONTRIBUTORS .................................................................................................................... ii PREFACE ......................................................................................................................................................................... 1 CHAPTER 1: DIAGNOSIS OF ADHD ................................................................................................................................... 3 CHAPTER 2: DIFFERENTIAL DIAGNOSIS AND COMORBID DISORDERS ............................................................................. 14 PREVALENCE OF COMORBIDITIES .................................................................................................................................. 14 OPPOSITIONAL DEFIANT DISORDER ............................................................................................................................... 16 CONDUCT DISORDER/AGGRESSION ............................................................................................................................... 17 ANTISOCIAL PERSONALITY DISORDER ............................................................................................................................ 18 BORDERLINE PERSONALITY DISORDER .......................................................................................................................... 19 ADDICTIONS ................................................................................................................................................................... 20 SUBSTANCE USE DISORDER ........................................................................................................................................... 20 ANXIETY DISORDERS ...................................................................................................................................................... 21 MAJOR DEPRESSIVE DISORDER ...................................................................................................................................... 22 BIPOLAR DISORDER ........................................................................................................................................................ 23 DISRUPTIVE MOOD DYSREGULATION DISORDER .......................................................................................................... 24 OBSESSIVE-COMPULSIVE DISORDER .............................................................................................................................. 25 TOURETTE SYNDROME AND TIC DISORDERS ................................................................................................................. 26 EATING DISORDERS ........................................................................................................................................................ 26 AUTISM SPECTRUM DISORDER ...................................................................................................................................... 27 SPECIFIC LEARNING DISORDER ...................................................................................................................................... 28 SPECIAL PRESENTATIONS ............................................................................................................................................... 29 Intellectual Giftedness ............................................................................................................................................... 29 Psychological Trauma ................................................................................................................................................ 30 Developmental Coordination Disorder ...................................................................................................................... 30 Epilepsy ...................................................................................................................................................................... 30 Brain Injury ................................................................................................................................................................ 31 Sleep .......................................................................................................................................................................... 31 Incontinence .............................................................................................................................................................. 32 CHAPTER 3: SPECIAL CONSIDERATIONS ACROSS THE LIFESPAN ...................................................................................... 33 OVERVIEW ...................................................................................................................................................................... 33 IMPACT/FUNCTIONAL DISABILITY ACROSS THE LIFESPAN ............................................................................................. 37 ACCIDENTS/RISKS ........................................................................................................................................................... 38 DRIVING ......................................................................................................................................................................... 39 CHAPTER 4: PSYCHOSOCIAL TREATMENT OF ADHD ...................................................................................................... 41 PSYCHOEDUCATION ...................................................................................................................................................... 41 PSYCHOSOCIAL INTERVENTIONS OVERVIEW ................................................................................................................ 45 What can be done at home? ..................................................................................................................................... 45 What can be done at school? .................................................................................................................................... 47 What can be done in the workplace? ........................................................................................................................ 50 MANUALIZED INTERVENTIONS ..................................................................................................................................... 51 Parent Management Training Models ................................................................................................................... 51 Social Skills Training ............................................................................................................................................... 51 Cognitive Behavioural Therapy .............................................................................................................................. 51 Mindfulness Training .............................................................................................................................................. 52 CHAPTER 5: PHARMACOLOGICAL TREATMENT OF ADHD ............................................................................................... 53 INTRODUCTION ............................................................................................................................................................. 53 MEDICATION CLASSIFICATION ...................................................................................................................................... 53 First-Line Treatments ............................................................................................................................................. 53 Second-Line Treatments ........................................................................................................................................ 54 Third-Line Treatments ............................................................................................................................................ 54 STEPPED APPROACH TO PRESCRIBING .......................................................................................................................... 54 STEP 1 - Setting Treatment Objectives ................................................................................................................... 54 STEP 2 - Medication Selection ................................................................................................................................ 55 STEP 3 -Titration & Monitoring .............................................................................................................................. 70 STEP 4 - Ongoing Follow-up ................................................................................................................................... 70 MANAGING SIDE EFFECTS ............................................................................................................................................. 71 Common Adverse Events ....................................................................................................................................... 71 When to Reduce the Dose, or Stop a Medication .................................................................................................. 72 How to Stop Medication ........................................................................................................................................ 72 Choosing to Change to a Different Medication ...................................................................................................... 73 Side Effects Management Techniques ................................................................................................................... 73 UNSATISFACTORY RESPONSE TO TREATMENT .............................................................................................................. 74 INFORMATION ON SPECIFIC MEDICATIONS .................................................................................................................. 75 Canadian Medication Tables per Age Group .......................................................................................................... 77 Psychostimulants ................................................................................................................................................... 80 Non-Stimulants ...................................................................................................................................................... 87 FREQUENTLY ASKED QUESTIONS ON ADHD MEDICATIONS .......................................................................................... 91 CHAPTER 6: TREATMENTS REQUIRING FURTHER RESEARCH .......................................................................................... 93 CONTRIBUTOR DISCLOSURES ......................................................................................................................................... 96 REFERENCES .................................................................................................................................................................. 98 INDEX OF TABLES AND FIGURES 1.1 Diagnostic and Statistical Manual 5 (DSM-5) Criteria of 4.3 Interventions at School, 47 ADHD Symptoms, 4 4.4 Interventions in the Workplace, 50 1.2 Diagnostic and Statistical Manual (DSM-5) Presentations, 5 5.1 Stepped Approach to Prescribing, 54 1.3 Diagnosis and Treatment – Children, 11 5.2 Factors to Consider for ADHD Medication Selection, 55 1.4 Diagnosis and Treatment – Adolescents, 12 5.3 Psychiatric and Medical Contraindications and Precautions 1.5 Diagnosis and Treatment – Adults, 13 for ADHD Medications, 59 2.1 Prevalence of Comorbidities, 14 5.4 Clinical Comparison of Long-Acting Medication, 62 2.2 Oppositional Defiant Disorder (ODD) Differentiation, 16 5.5 Drug Interactions - Amphetamines, 63 2.3 Conduct Disorder (CD) Differentiation, 17 5.6 Drug Interactions - Methylphenidate, 64 2.4 Antisocial Personality Disorder (ASPD) Differentiation, 18 5.7 Drug Interactions – Guanfacine XR, 65 2.5 Borderline Personality Disorder (BPD) Differentiation, 19 5.8 Drug Interactions – Atomoxetine, 66 2.6 Anxiety Disorder Differentiation, 22 5.9 Common Adverse Table, 71 2.7 Major Depressive Disorder Differentiation, 23 5.10 Second or Third Line Treatment Considerations, 74 2.8 Bipolar Disorder (BD) Differentiation, 24 5.11 Medical Treatment for ADHD – Children (6-12 Years), 77 2.9 Disruptive Mood Dysregulation Disorder (DMDD) 5.12 Medical Treatment for ADHD – Adolescents (13-17 Years), Differentiation, 25 78 2.10 Autism Spectrum Disorder (ASD) Differentiation, 27 5.13 Medical Treatment for ADHD – Adults (18+), 79 3.1 Developmental Impact of ADHD, 33 5.14 Amphetamine Products, 81 4.1 ADHD Myths, 42 5.15 Methylphenidate Products, 84 4.2 Interventions at Home, 46 5.16 Non-Stimulant Products, 87 Contents of CADDRA ADHD ASSESSMENT eTOOLKIT (USB key) Step-By-Step Guide to ADHD • CADDRA ADHD Patient Transition Form • Diagnosis and Treatment - Children • JDQ (Jerome Driving Questionnaire) • Diagnosis and Treatment - Adolescents • CADDRA ADHD Assessment Form (optional use) • Diagnosis and Treatment - Adults Templates Assessment, Treatment and Follow-Up Forms • Educational Accommodation Letter • SNAP-IV Teacher and Parent Rating Scale • Employment Accommodation Letter • ASRS (Adult ADHD Self-Rating Scale) • WFIRS-P (Weiss Functional Impairment Rating Patient Information Scale-Parent) • CADDRA ADHD Information and Resources Handout • WFIRS-S (Weiss Functional Impairment Rating • Instructions for Completing Selected Scale-Self) Questionnaires for Health Practitioners • WSR II (Weiss Symptom Record II) • CADDRA Teacher Assessment Form Visit www.caddra.ca to access: • CADDRA Clinician ADHD Baseline/Follow-Up à ADHD Psychosocial Treatments Chart Form à ADHD Pharmacological Treatments Chart • CADDRA Patient ADHD Medication Form à Documents in the CADDRA ADHD Assessment Toolkit i Canadian ADHD Practice Guidelines The Canadian ADHD Practice Guidelines, 4th Edition, is dedicated to children, adolescents and adults with ADHD, and their families. 4th Edition Guidelines Editors Doron Almagor MD, FRCPC, Director, The Possibilities Clinic, Toronto, ON; Chair, Canadian ADHD Resource Alliance (CADDRA), ON Don Duncan MD, FRCPC, Assistant Clinical Professor, Psychiatry, University of British Columbia, BC Martin Gignac MDCM, FRCPC, Child and Adolescent Psychiatrist; Clinical Associate Professor, Université de Montréal, QC Former Guidelines Editors / Chairs of Guidelines Committee 3rd Edition Umesh Jain MD, DABPN, Ph.D., M.Ed., FRCPC Associate Professor, Psychiatry, University of Toronto, ON Margaret Weiss MD, Ph.D., FRCPC, Clinical Professor, Psychiatry, University of British Columbia, BC Annick Vincent MD, M.Sc., FRCPC Professeur de clinique, département de psychiatrie et de neurosciences, Université Laval, QC 2nd Edition Umesh Jain MD, DABPN, Ph.D. M.Ed., FRCPC Associate Professor, Psychiatry, University of Toronto, ON Attila Turgay MD 1st Edition Umesh Jain MD, DABPN, Ph.D. M.Ed., FRCPC Associate Professor, Psychiatry, University of Toronto, ON External Reviewers 4th Edition Heidi Bernhardt, RN, President and Executive Director, CADDAC (Centre for ADHD Awareness, Canada), Markham, ON Thomas E. Brown, Ph.D., Adjunct Clinical Associate Professor of Psychiatry & Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA James Felix MD, CCFP, University of Victoria Health Services, BC Craig Surman MD, Assistant Professor of Psychiatry, Harvard Medical School, MA; Scientific Coordinator, Adult ADHD Research Program, Massachusetts General Hospital, MA Chris Wilkes MB, IAAP, FRC Psych., Ch.B., DCH, B.Sc., M. Phil., FRCPC Professor, Department of Pediatrics & Psychiatry, University of Calgary, AB 3rd Edition Thomas E. Brown Ph.D., Adjunct Clinical Associate Professor of Psychiatry & Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA Peter S. Jensen MD, President & CEO, The Reach Institute; Professor of Psychiatry, Mayo Clinic, Rochester, MN, USA Sarah Shea MD, FRCPC, Associate Professor, Pediatrics, Dalhousie University, Halifax, NS John Yaremko MD, FRCPC, Assistant Professor, Pediatrics, McGill University, Montreal, QC 2nd Edition Samuel Chang MD, FRCPC, Clinical Associate Professor, Faculty of Medicine, University of Calgary, AB Laurence Jerome MB, Ch.B, M.Sc., FRC Psych., FRCPC, Adjunct Professor, Psychiatry, Western University, ON Annick Vincent MD, M.Sc., FRCPC Professeur de clinique, département de psychiatrie et de neurosciences, Université Laval, QC ii Authors and Contributors, 4th Edition Chapters Committee Members Affiliation Preface: Doron Almagor MD, FRCPC Director, The Possibilities Clinic, Toronto, ON; Chair, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Don Duncan MD, FRCPC Assistant Clinical Professor, Psychiatry, University of British Columbia, BC Umesh Jain MD, FRCPC, Associate Professor, Psychiatry, University of Toronto, ON DABPN, Ph.D., M.Ed. Chapter 1: Lauri Alto MD, Ph.D., FRCPC Associate Professor, Pediatrics and Child Health, University of Manitoba, MB Matt Blackwood MD, CCFP, Family Practitioner, Mission, BC FCFP Patricia Ainslie Gray MD Medical Director, Springboard Clinic, Toronto, ON Julia Hunter MD, FRCPC, Psychiatrist, Vancouver, BC M.Sc. Simon-Pierre Proulx MD Groupe de médecins de famille, Loretteville, Québec, QC Declan Quinn MD FRCPC Professor, Psychiatry, University of Saskatchewan, Saskatoon, SK Kristi Zinkiew MD, FRCPC Pediatrician, Mill Bay, BC Chapter 2: Don Duncan MD, FRCPC Assistant Clinical Professor, Psychiatry, University of British Columbia, BC Martin Gignac MD, FRCPC Child and Adolescent Psychiatrist; Clinical Associate Professor, University of Montreal, QC Chapter 3: Andrew Hall MD, FRCPC Assistant Professor, College of Medicine, University of Manitoba, MB Joseph Sadek MD, FRCPC, Associate Professor, Department of Psychiatry, Dalhousie University, DABPN, B.Sc. Pharm., MBA Halifax, NS Sara Binder MD, FRCPC Psychiatrist, Psychiatric Adult Services, Foothills Medical Centre, University of Calgary, AB Natalie Grizenko MD, FRCPC Associate Professor, McGill University; Medical Director of the Severe Disruptive Behaviour Disorders Program and ADHD Clinic, Douglas Mental Health University Institute., QC Chapter 4: Geraldine Farrelly LRCP, Developmental Pediatrician; Clinical Associate Professor, Pediatrics and LRCSI, DCH (Irel), D.OBST, Psychiatry, University of Calgary, AB FRCPC Karen Ghelani, Ph.D., C. Psych Director, Chrysalis Psychological and Counselling Services, Markham, ON; Clinical Adjunct Faculty, York University Psychology Clinic, Toronto, ON Chapter 5: Doron Almagor MD FRCPC Director, The Possibilities Clinic, Toronto, ON; Chair, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Sylvie Bourdages, B. Pharm. Pharmacist, Montreal, QC Craig Surman MD Assistant Professor of Psychiatry, Harvard Medical School, MA; Scientific Coordinator, Adult ADHD Research Program, Massachusetts General Hospital, MA Annick Vincent MD, M.Sc., Clinique FOCUS, QC; Professeur de clinique, département de psychiatrie et de FRCPC neurosciences, Université Laval Azadeh Alizadeh Rikani MD, Ph.D. student, Psychiatric Science, University of Montreal, QC Chapter 6: M.Sc., ECFM Sylvie Bourdages, B. Pharm. Pharmacist, Montreal, QC Marc Tannous MD Psychiatric Resident, University of Montreal, QC Valerie Tourjman MDCM, Clinical Associate Professor, Department of Psychiatry, University of FRCPC, Ph.D. Montreal, QC iii Additional Contributors Penny Corkum, Ph.D., R. Psych., Professor, Department of Psychology and Neuroscience, Dalhousie University, NS Samuel Chang MD, FRCPC, Clinical Associate Professor, Faculty of Medicine, University of Calgary, AB Paul Dorian MD, Division of Cardiology (Pediatrics), Hospital for Sick Children, Toronto, ON; Professor of Pediatrics, University of Toronto, ON Lily Hechtman MD, FRCPC, Professor of Psychiatry and Pediatrics, McGill University; Director of Research, Division of Child and Adolescent Psychiatry, McGill University; Director of ADHD Psychiatry Services, McGill University Health Center (MUHC), QC David Goodman MD, FAPA, Assistant Professor, Department of Psychiatry and Behavioral Sciences, John Hopkins School of Medicine, MD Harriet Greenstone, M.A., Ph.D., OPQ, Adjunct Professor, University of Ottawa, ON; Director, Centre MDC, ON Robert Hamilton MD, Division of Cardiology, St. Michael’s Hospital, Toronto, ON; Professor of Medicine and Pharmacology, University of Toronto, ON Laurence Jerome MB, Ch.B., M.Sc., FRC Psych., FRCPC, Adjunct Professor of Psychiatry, Western University, ON Derryck Smith MD, FRCPC, Clinical Professor Emeritus, Psychiatry, University of British Columbia, BC Rosemary Tannock, Ph.D., Professor Emerita and Senior Scientist, University of Toronto, ON Michael Zwiers, R. Psych, Ph.D., Assistant Professor, University of Calgary, AB Editorial Coordinators Anne-Claude Bedard, Ph.D., Assistant Professor, Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, University of Toronto, ON Amanda Edwards, B.A., Education Coordinator, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Niamh McGarry, Executive Director, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Additional Contributors to previous editions: Krista Forand, M.Ed., Calgary Learning Centre, Calgary, AB Rosalia Yoon, Ph.D., Centre for Addiction and Mental Health, Toronto, ON Guidelines and eToolkit Design & Layout: Kim Cheetham and Shee Creative, Sydney, Nova Scotia iv PREFACE CANADIAN ADHD PRACTICE GUIDELINES INTRODUCTION The purpose of the Canadian ADHD Practice Guidelines is to improve the quality of care and health care outcomes for all individuals with Attention Deficit Hyperactivity Disorder (ADHD) in Canada. The Guidelines: • Cover the lifespan of the disorder. • Are based on published evidence. • Involve expert consensus when there is a lack of evidence. • Offer practical clinical advice. • Provide assessment, treatment and follow-up questionnaires. • Include templates for requesting accommodations. • Recommend optimizing care on an individual basis. • Assist healthcare providers to empower their patients to make informed choices in a collaborative process of care. • Contain information specific to the Canadian healthcare system. The Guidelines are targeted at health care professionals but may also be of use to additional stakeholders (policy makers, funding bodies, educators) and individuals with ADHD and their families. The tools included in the Guidelines were selected based on their validity, reliability and accessibility. These Guidelines were developed to provide information and user-friendly tools to support Canadian health care professionals diagnose and treat ADHD across the lifespan. These Guidelines are not intended to replicate or replace the many excellent textbooks on ADHD. The evolution of the 4th Edition The Canadian ADHD Practice Guidelines are produced and funded by the Canadian ADHD Resource Alliance (CADDRA), a national, independent, not-for-profit association whose members are drawn from family practice, pediatrics, psychiatry (child, adolescent and adult), psychology and other health professions. The Guidelines have been in constant review for over ten years The fourth edition of the Canadian ADHD Practice Guidelines evolved from earlier editions published in 2006, 2008, and 2011. A multidisciplinary team that included ADHD specialists, pediatricians, psychiatrists, psychologists, family physicians, pharmacists, nurses, educators and community stakeholders from across Canada and from the US contributed to its writing and review. Disclosures and Funding Conflicts of interest were recorded for all individuals that were a part of the process and are included in the Guidelines. As it is the case since the 1st edition of the Canadian ADHD Guidelines, all authors have donated their time and shared their expertise without receiving any financial contribution. The final draft of the 4th edition was independently reviewed by a range of relevant stakeholders (e.g. adult psychiatrist, child and adolescent psychiatrist, psychologist, patient advocate/nurse, family physician). The Guidelines development process was fully funded by CADDRA and occurred without external financial grants. Endorsements These Guidelines are endorsed by the Centre for ADHD Awareness, Canada (CADDAC). 1 CADDRA GUIDELINES – CORE PRINCIPLES These Guiding Principles were developed and approved by the CADDRA Board. Principles for Assessment and Diagnosis 1. The clinician has to be fully licensed and adequately trained in order to ensure Diagnostic and Statistical Manual 5 (DSM-5) diagnostic criteria for ADHD are fully met [1]. 2. The assessment needs to reflect an understanding of multi-systemic issues that may confound or complicate the ADHD diagnosis (e.g. the educational/vocational, psychosocial, psychiatric and medical interfaces). 3. Symptoms and functional impairment need to be assessed. Using valid, reliable and sensitive instruments helps to evaluate frequency, severity, and outcome. 4. Regular documentation of symptoms and functional impairment, if possible at each visit, helps to track progress and monitor outcome. 5. Establishing collaborative treatment goals with the patient (and their family when appropriate) ensures that outcomes are patient-centred. 6. The results of the assessment need to be communicated to the patient and their family with clarity and compassion. Abbreviations ADHD Attention Deficit Hyperactivity Disorder DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th Edition AERS Adverse Event Reporting System DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition AMP Amphetamines GXR Guanfacine XR ASD Autism Spectrum Disorder MDD Major Depressive Disorder ASPD Antisocial Personality Disorder MRR Mortality Rate Ratio ASRS Adult ADHD Self Report Scale MPH Methylphenidate ATX Atomoxetine Hydrochloride NF Neurofeedback BD Bipolar Disorder OCD Obsessive Compulsive Disorder BPD Borderline Personality Disorder ODD Oppositional Defiant Disorder CADDRA Canadian ADHD Resource Alliance RCT Randomized Clinical Trials CADDAC Centre for ADHD Awareness, Canada S-ADHD Secondary Attention Deficit Hyperactivity Disorder CBT Cognitive Behavioural Therapy SNAP-IV Swanson, Nolan and Pelham Teacher and Parent Rating Scale CD Conduct Disorder SLD Specific Learning Disorder CHADD Children and Adults with ADHD SUD Substance Use Disorder DCD Developmental Coordination Disorder TS Tourette's Syndrome DEX Dextro-amphetamine WFIRS-P Weiss Functional Impairment Scale – Parent Report DMDD Disruptive Mood Dysregulation Disorder WFIRS-S Weiss Functional Impairment Scale – Self-Report DSM-III Diagnostic and Statistical Manual of Mental WSR-II Weiss Symptom Record II Disorders, 3rd Edition 2