Clinical guidance on pharmacotherapy for the treatment of attention-deficit hyperactivity disorder (ADHD) for people with intellectual disability

Abstract

Introduction: ADHD causes significant distress and functional impairment in multiple domains of daily life. Therefore, diagnosis and treatment are important to improve the quality of life of people. The pharmacotherapy for ADHD is well established but needs systematic evaluation in Intellectual Disability (ID) populations. Areas covered: This paper reviews the ADHD pharmacological treatment in people with ID using the PRISMA guidance for scoping reviews to help identify the nature and strength of evidence. Expert opinion: In the last 20 years, seven randomized controlled trials have evaluated pharmacotherapies for ADHD in people with ID; five looking at methylphenidate. Generally, studies were underpowered; all but two had less than 25 participants. Of the two larger trials one was single blinded and therefore open to bias. Only two used a parallel-group method, the remainder were mostly short crossover trials; not ideal when measuring behavioral and psychological parameters which are long standing. The remaining evidence is made up of observational studies. Methylphenidate and atomoxetine, particularly at higher doses, have shown clear benefits in people with ID. Most people with ID tolerated ADHD medications well. Benefits were seen in behavioral and/or cognitive domains. The evidence base is limited, though promising, for dexamfetamine, clonidine, and guanfacine.

Combined Medication with Stimulants and Non-stimulants for Attention-deficit/hyperactivity Disorder

“…In this study, few patients with neurodevelopmental disorders such as intellectual disability were treated with combined drugs to treat behavioral problems. Based on the clinical guidelines for the treatment of ADHD for people with intellectual disability, MPH, and ATX at higher doses have shown clear benefits in behavioral and/or cognitive domains [ 24 ].…”

Aggressive challenging behavior in adults with intellectual disability: An electronic register-based cohort study of clinical outcome and service use

“…https://doi.org/10.1192/j.eurpsy.2022.2336 Published online by Cambridge University Press ADHD is increasingly recognised in adults with intellectual disability and may underlie some presentations of challenging behaviour [6,35], however can present differently in those with intellectual disability and standard diagnostic criteria may be less applicable in this population [37]. ADHD is a treatable condition [36]; screening and access to assessments with specialists is necessary to avoid diagnostic overshadowing and ensure appropriate management.…”

Assessing and managing attention-deficit hyperactivity disorder in people with intellectual disability

“…Pharmacological treatments are effective in people with intellectual disability and moderate to severe ADHD. However, very few studies have looked at the effectiveness of ADHD medications in people with intellectual disability and most of these were undertaken in children (Courtenay 2016; Miller 2020). The two main classes of ADHD medication are stimulants and non-stimulants (Box 3).…”

“…In clinical practice, doses of ADHD medications prescribed for people with intellectual disability are reported to be low (Miller 2020). This may not lead to full control of ADHD symptoms, and therefore gradual titration of doses while monitoring for side-effects is important to optimise treatment.…”