• ADHD (attention deficit/hyperactivity disorder) is a neurodevelopmental syndrome with onset in childhood that often continues to adulthood.
  • The primary symptoms include problems with the regulation of attention and activity, and impulsiveness.
  • In addition, nearly all patients have problems with executive functions, often with regulation of emotions and behaviour.
  • Concomitant developmental and psychiatric disturbances are common and must be taken into account when planning the treatment and rehabilitation.
• To diagnose ADHD, extensive assessment of the symptoms and the patient's life situation is needed. Various symptom inquiry forms and other symptom assessment methods are suitable for use as part of the total assessment but not as the sole diagnostic method.
• When making the diagnosis in adults, attention should be paid to the age when the symptoms began and to the life span continuum. In addition, differential diagnostic factors explaining or aggravating the symptoms (somatic or psychiatric disorders and habits that are unfavourable for brain function) should be excluded and treated.
• Untreated ADHD increases accident proneness and is associated with poorer performance in studies and in working life. It also increases the risk of substance use disorder, social exclusion and criminal conduct.
• The treatment of ADHD consists of arrangements supporting functional ability and symptom control at home, in day care, at school, in the study place and in working life, of various forms of psychosocial treatment and medication, as necessary. Tenacious treatment of the symptoms improves the quality of life and reduces the known risks.

• An estimated 5 to 7% of school-aged children and 3 to 4% of adults have ADHD. Its prevalence decreases with age.
• The symptoms of ADHD relatively often (in 40–70% of cases) continue from childhood to adulthood.
  • In some individuals, ADHD symptoms may be mild in childhood due to e.g. an environment that supports functional capacity, and ADHD is recognized only in adulthood when the symptoms interfere with functional capacity more.
• ADHD is diagnosed 2 to 3 times as often in boys as in girls but the difference between men and women affected is smaller. Children born towards the end of the year have more diagnoses than those born early in the year.

• Genetic predisposition explains about 60–80% of occurrence of ADHD.
• Environmental factors may affect the occurrence of ADHD by regulating the activity of risk genes, by causing changes in the brain function and the course of normal development, and by affecting the symptoms' severity and the level of harm they cause.
  • Risk factors during pregnancy include, among others, being exposed to maternal alcohol consumption or substance use, and fetal asphyxia. Severe maternal stress and use of pharmaceuticals during pregnancy may also be significant.
  • Risk factors associated with the family, such as interactive problems and conflicts, increase oppositional defiant and behavioural symptoms, in particular, and impair functional ability but do not alone cause ADHD.
  • Severe early experiences of maltreatment appear to predispose people to the development of ADHD symptoms.
  • Due to genetic factors, both a parent and a child in a family often have ADHD. The parent’s ADHD will affect the child’s functional capacity. Good management of the parent’s symptoms will also reduce the child's symptoms.
  • Excessive exposure to fast-tempo tv programmes and videos before the age of 3 years would appear to increase concentration problems at school age. Excessiveuse of digital devices may increase restlessness and concentration problems in people of any age especially if it diminishes the time spent sleeping and exercising. In early years, excessive use of digital devices by the child and also by the parents decreases interactive situations and thus affects the development of linguistic and regulation skills, for example.
• The essential findings related to brain activity are associated with abnormal dopamine- and noradrenaline-mediated nerve activity in brain regions regulating attention, impulse control, alertness and activity and in connections between such regions.
  • Abnormal regulation of alertness may also be associated with sleep problems (the patient not being able to calm down sufficiently).

• Occasional symptoms of inattention, hyperactivity or impulsiveness are quite common. In patients with ADHD, symptoms that clearly impair functional ability are frequent and present for a long time, and they occur in many different situations and environments.
• Three types of ADHD can be distinguished.
  • Attention deficit disorder (ADD) involving predominantly concentration problems without associated impulsiveness or hyperactivity
  • Overactivity and impulsiveness without significant concentration problems
  • A mixed type of disorder with problems in all the main symptom areas
• All types should be diagnosed under the ICD code F90.0. The predominant symptoms can be further defined verbally, as necessary, if the patient record system being used allows this.
• The manifestations of the symptoms are different at different ages.
  • Difficulty in activity regulation most typically appears as hyperactivity, difficulty acting appropriately calmly, but may also appear as inability to initiate activity and as sluggishness.
    • In children below school age, hyperactivity often appears as physical restlessness, constant moving, climbing, running, vocalizing and fussing all the time.
    • In school-aged children, it may appear as constant activity, restlessness and difficulty sitting still in class and in other situations requiring staying still.
    • In adults, hyperactivity may not manifest similarly but may appear instead as internal restlessness and as avoiding events where they would need to remain still.
    • Adults often learn to direct their hyperactivity to socially more appropriate forms but keeping their hyperactivity under control may take all their attention in the situation.
  • In children below school age, the difficulty of regulating attention may appear as a short attention span when playing, in school-aged children as distractibility, being absorbed in thought, making careless mistakes and forgetting their belongings. In adults, inattentiveness may manifest, for example, as absent-mindedness, difficulty in maintaining concentration in the long term even if they try, as forgetting things and tasks, carelessness, constant tardiness and repeated no-shows at doctor's (or other health care) appointments and as a tendency to get involved in secondary tasks instead of those of primary importance. Need for support from other people to succeed in life management that is unusual for the person’s age is also common.
    • There may also be excessive concentration at times, meaning that patients immerse themselves in matters of interest to such an extent that they lose their sense of time and situation.
  • In children below school age, impulsiveness often appears as a short attention span when playing, as unpredictable running around and fast activity. In school-aged children, impulsiveness may appear as inability to wait for their turn in games, when playing or in discussions and as unconsidered activity. In adults, impulsiveness may lead to sudden changes of place of study or workplace, difficulties in relationships and financial problems due to unplanned use of money. Quick and strong emotional reactions are also typical.
• The degree of disturbance caused by the symptoms depends on environmental factors. For example, symptoms are more likely to appear in a large group than in a one-to-one situation.
  • Motivation and pleasure from the activity affect concentration. It is easier to concentrate on interesting matters producing immediate reward than on tasks experienced as arduous that produce a reward only later. People with ADHD often fail to concentrate on tasks requiring effort and start to avoid such tasks.
  • Factors affecting physical wellbeing (lack of physical activity or sleep, hunger, excessive use of digital devices), strong emotions (excitement, anger) and stressful situations (disproportionate demands, conflicts at home, bullying) intensify symptoms.
  • Symptoms may not occur at all in a peaceful environment, within interesting activity, when movement that supports alertness control is possible.

Diagnostic criteria

• ADHD is a symptomatic diagnosis; there are no specific diagnostic examinations.
• An extensive assessment of the overall situation is necessary to make the diagnosis and for differential diagnosis.
  • Extensive history (course of childhood development and any abnormalities in it, subsequent course of life, current and past symptoms, need for support, any other diseases/disorders and medication to treat them, history of examinations and treatments, current stress factors, family situation, family history). In adolescents and adults, also history of intoxicant use.
  • Age at onset of symptoms, duration of symptoms and their occurrence in various situations
    • In children, preferably ask the day care centre / school directly; in adults, observations made by someone close are also useful.
    • Review of factors affecting the patient's symptoms and functional ability
    • When diagnosing adults, it must be ensured that symptoms have been present since primary school age at the latest (about 7 to 12 years of age). In addition to interviewing the patient, documents related to their childhood should be used and a parent, for example, interviewed as necessary. The spouse / other close person may recognize current problems and be able to describe them well.
    • Investigation of any harm/consequences from the symptoms; just having ADHD features can be distinguished from disorder-level problems by the patient’s functional ability. When assessing the patient’s functional ability, the effect of implemented support measures should also be examined (successful support measures improve functional ability even in patients with disorder-level problems).
  • Clinical somatic, psychiatric and neurological (differential diagnostic) examination
  • Examinations required for differential diagnosis
    • Laboratory tests should be utilized, as necessary, to exclude any other causes for the symptoms (anaemia, thyroid function disorders, coeliac disease, etc.), and to test for intoxicant abuse in adolescents and adults.
    • Brain imaging and EEG are usually unnecessary unless indicated for differential diagnosis (suspicion of neurological disorder, injuries in the head area). Such examinations are usually done in specialized care.
    • A psychological or neuropsychological examination is not indispensable for diagnosis but it may be necessary for differential diagnosis and for treatment and rehabilitation. It is useful particularly in recognizing learning difficulties, and in adults the need can be assessed by investigating the patient’s learning history and school reports, for instance. Find out about locally available screening tests (checklists) for dyslexia.
    • In children, assessment by a speech or occupational therapist may be necessary to obtain an overall picture of the situation. In adults, too, assessment of functional ability may be needed as part of the investigation, particularly if the patient has comorbidities or poor symptom awareness.
• According to the diagnostic criteria in ICD-10, the patient must have 6 symptoms of impaired attention and 6 symptoms of hyperactivity-impulsiveness of the total of 18 symptom criteria.
  • In patients of 17 years or older, 5 current symptoms of impaired attention and/or hyperactivity-impulsiveness are sufficient (according to the DSM-5 criteria).
  • ICD-11 does not define the exact number of symptoms.
• Symptoms usually appear as early as childhood. Nevertheless, they may not have been identified until school age and, according to the DSM-5 criteria, it is sufficient for several symptoms to have occurred before the age of 12 years.
• Care must be taken in making the diagnosis before school age (about 7 years), and reliable diagnosis may not be possible in preschool-age children before the age of 5 years.
• When diagnosing adults, it must be ensured (from documents, for instance) that symptoms have been present since primary school age at the latest (about 7 to 12 years of age). It is not necessary, however, to verify that all diagnostic criteria were met in childhood years. It is enough that there were several symptoms of inattention or hyperactivity/impulsiveness.
  • Support measures provided during childhood, such as more intensive parental support for homework, lengthy need for guidance in daily activities or pedagogical arrangements at school may also suggest problems with functional ability.
• Symptoms significantly affecting the patient’s functional ability must occur in several types of situation and with different people but not necessarily in every situation, such as at a doctor's office or in connection with a psychological examination.
  • Symptoms may be different in different situations, and the severity of symptoms may vary.
  • Observations related to different functional abilities in different situations may help to find means for alleviating the symptoms.
  • Being successful at school or in working life does not automatically exclude the possibility of having ADHD.
• Having another psychiatric diagnosis does not exclude the diagnosis of ADHD if the patient has clearly separate but simultaneous disorders. There may be some overlapping symptoms. For reliable differential diagnosis, it would be good to have tried treating psychiatric symptoms or substance use disorder before investigating ADHD, but in cases refractory to treatment, assessment can be attempted in specialized care.
• Find out about local policies concerning diagnostic criteria applied in different age groups.

Questionnaires and other symptom assessment methods

• Either ADHD questionnaires or methods surveying various reactions or performance or functional ability can be used to facilitate the assessment of symptoms. Nevertheless, the diagnosis must not be based on results from any single method. Their sensitivity in detecting ADHD symptoms is good but they are not sufficiently specific and can therefore produce false positive results.
• Questionnaires help with systematic evaluation of symptoms and follow-up of response to treatment.
  • The information value and reliability of such questionnaires improve if they are used by several parties (in child patients the teacher, parents, the child). In adults, self-assessment questionnaires as such are insufficient for reliable assessment of symptoms.
  • Respondents should be asked to tell in their own words examples of how the claimed symptoms appear in practice and how they have affected their functional ability. This will increase the reliability of such questionnaires and help to recognize false positive or negative replies of other causes.
  • Questionnaires suitable for surveying symptoms include the ADHD-RS questionnaire https://www.guilford.com/books/ADHD-Rating-Scale-5-for-Children-and-Adoles... and for adults ASRS https://www.mdcalc.com/adult-self-report-scale-asrs-adhd and DIVA http://www.divacenter.eu, for example.
  • Questionnaires surveying mental functional ability more extensively include 5-15R (which can also be used to survey symptoms of adults in their childhood) https://www.5-15.org/download and SDQ https://www.sdqinfo.org/, for example.
  • Tests measuring reactions, physical activity, performance or executive functions (such as the Continuous Performance Test (CPT) or the Quantified Behavioral Test (QbTest)) can be considered as part of the diagnostic workup as long as their results are assessed in relation to other symptom assessment.
    • There is little scientific evidence so far regarding methods of examining executive functions based on virtual reality.
• Find out about locally available versions of these tests.

• Hyperactivity in a child below school age may, for instance, be due to an autism spectrum disorder, a language disorder, motor or sensory disorders or more extensive developmental delay.
• In school-aged children, it is additionally important to include learning difficulties, anxiety disorders, oppositional defiant and conduct disorder, post-traumatic disorders and depression, for instance, in the differential diagnosis.
• In adolescents and adults, it is important to include affective syndromes (depression, bipolar disorder), substance use disorders, psychotic disorders (such as the prodromal stage in schizophrenia), anxiety disorders and emotionally unstable or antisocial personality in the differential diagnosis.
  • In a person with substance use disorder, it should be confirmed reliably whether ADHD symptoms occurred already before substance use began. Such investigation can be started even if substance use continues. The person should abstain from substances for 1–3 months before current symptoms are assessed. Withdrawal symptoms may resemble those of ADHD. Any symptoms that occurred during previous periods of abstinence should also be considered.
  • Learning difficulties or verbal difficulties that were not recognized during growth or were recognized but forgotten are relatively common also in adults and may lead to a partly similar clinical picture and problems with functional ability as in ADHD. These may coexist, too.
• Possible physical causes include epilepsy (absence seizures), other neurological disorders (such as neurofibromatosis) and sequel of brain injury.
• Restlessness and inattention may also be due to sleep disorders (sleep apnoea, restless legs, long-term sleep deprivation).
• Traumatic experiences or current stress (being bullied, changes in family situation, losses, abuse, attachment disorders) may also cause similar symptoms. Nevertheless, it should be remembered that symptoms of ADHD as such predispose to stress, negative experiences affecting the self-image, and maltreatment.
• If the patient says that an ADHD-type clinical picture only began in adolescence or adulthood, the possibility of other underlying diseases, psychiatric disorders or the acquired attentional disturbance ADT (attention deficit trait) should first be excluded ⁴ .

• As many as 75–80% of patients have some simultaneous psychiatric disorder or substance use disorder.
• Children often have various types of learning difficulties, developmental language or motor disorders or executive or sensory regulation problems simultaneously with ADHD. These may affect the person’s functional ability even in adulthood.
  • Oppositional defiant and/or conduct disorders are also common (Conduct disorders in children and adolescents).
• Sleep disorders (Sleep disorders in children and adolescents) are more common in ADHD patients of any age than in other people. Falling asleep is often delayed and the quality of sleep impaired.
• In 50–90% of patients, ADHD symptoms are associated with depression (Childhood depression) (Treatment of depression in association with other psychiatric disorders) or problems associated with self-image, self-esteem or social interactive skills, often secondary to receiving inadequate support.
• Anxiety disorders, such as obsessive-compulsive disorder (Obsessive-compulsive disorder (OCD) in children) (Obsessive-compulsive disorder (OCD)), are also more common.
• ADHD may occur as a part of a more severe neuropsychiatric entity, possibly with symptoms that occur in the autism spectrum (Autism spectrum disorders) and/or tics (Tic disorders in childhood). It is possible to have several developmental neuropsychiatric disorders at the same time.
• ADHD is a risk factor for developing a substance use disorder and for smoking. Pharmacological treatment of ADHD will not increase the risk. The risk of abuse must be considered when using medication.

• Good treatment of ADHD involves providing sufficient information and counselling (psychoeducation), psychosocial treatment, and, as necessary, pharmacological treatment.
  • Combination of various forms of treatment and, in particular, methods for making daily life run smoothly is often needed.
  • The need and suitability of pharmacological treatment should be considered in all adults with the diagnosis.
• It is important to take care of general wellbeing (sleep, physical exercise, diet, positive interaction, moderate use of digital devices) to support functional ability and to control ADHD symptoms.
• When planning treatment, other simultaneous disorders, problems affecting the overall situation, in minors coping of the parents and in adults coping of the spouse and the whole family and working ability must be considered.
• In children below school age, the first-choice treatment is psychosocial treatment started in primary care.
  • Parents benefit from guidance and sufficient support. Parenting skill groups also provide peer support.
  • Pharmacological treatment is rarely used and it should be started in specialized care.
• In school-aged and older patients pharmacological treatment can be started simultaneously with other treatment or if other forms of support have not helped sufficiently.

Psychosocial treatments

• Psychosocial treatments may involve various methods of supporting functional ability (guidance, environmental modification), support measures and practising of skills alone or in a group. It is often most sensible, especially in children, to provide such treatment largely as a part of the patient's daily life, but various forms of individual or group therapies may be included, as necessary.
  • The need for occupational therapy, neuropsychological rehabilitation and speech therapy must be assessed individually. In adults, these are often poorly available. It is worthwhile to provide neuropsychological rehabilitation primarily for patients who in addition to ADHD have concomitant learning difficulties, for example, and currently need rehabilitation for such difficulties due to their ongoing studies or work.
• Cognitive behavioural interventions reduce ADHD symptoms in adults [Evidence Level: A].
  • Online therapy is available for adults but referral by a physician may be needed.
  • Family therapy does not appear to be effective in the treatment of ADHD symptoms but it may be necessary for other reasons .
• An attempt should be made to alleviate ADHD symptoms and increase experiences of success by guiding the patient's behaviour and eliminating disturbing environmental factors. This can, for instance, be done by employing anticipation, advance planning, immediate feedback, structuring, and splitting tasks into smaller parts. Reward systems are also beneficial, as are concrete aids (e.g. pictograms, visual clock, daily routine).
  • Neuropsychiatric coaching is solution- and resource-focused rehabilitation implemented in daily life at home, for children and adolescents at school, for adults at work, and depending on the person’s needs in other environments. It usually involves methods of coping in everyday life, and practising of various skills.
• Parent training [Evidence Level: C] will help parents to recognise their child's behaviour and factors affecting it and to guide the child's behaviour in the desired direction.
  • Parent training can be provided individually for each family or in groups. Find out about local possibilities.
  • Written material can be used to support the training.
  • ADHD symptoms may affect the child-parent relationship and lead to a vicious circle of negative interaction that should be broken. ADHD in a child also increases the risk of conflicts and relationship problems between the parents.
• Various kinds of support arrangements in day care and at school improve the functional capacity of children with ADHD. These may be started as soon as the problems have been observed, based on a pedagogical assessment, even in the absence of a diagnosis.
  • Close cooperation between school and home (and the place of treatment) is necessary both in planning and in implementing support measures.
  • The most common measures include structuring, dividing tasks into smaller parts, anticipation, immediate feedback and reward systems. Allowing non-disturbing movement to maintain alertness often facilitates work in class (e.g. sitting on a gym ball, playing with blue tack). Sufficient guidance during breaks and other free activities will reduce conflicts.
  • Some children and adolescents need special arrangements, such as more time for answering questions in exams, support by an assistant, differentiated tuition in various situations or subjects or small group tuition.
  • Based on a medical certificate, ADHD can be taken into consideration in taking and/or assessing the matriculation examination, and support is available for vocational studies as well.
  • Expertise is also needed for the guidance of studies and and careers advice. Practical work training can also be used to support adults with ADHD to cope better with applying for a job or with starting in a new job.
• Adjustment training courses for people of various ages and peer support activities are readily available.
• Some families will benefit from the types of support offered by social services, such as people or families providing support.
• If a parent has clearly disturbing ADHD or other problems affecting their functional ability, they also need appropriate treatment and rehabilitation.

Pharmacotherapy

• Correctly implemented pharmacological treatment of ADHD is effective and safe.
• Psychostimulants (methylphenidate, lisdexamphetamine, dexamphetamine), atomoxetine or guanfacine can be used. Of these, dexamfetamine and guanfacine are officially indicated in the treatment of minors, only.
  • The action of psychostimulants is mainly dopamine-mediated, with rapid onset about 30–60 minutes after taking the medication. Their effect lasts 4–12 hours depending on the product.
  • The action of atomoxetine is mainly noradrenaline-mediated. It gradually intensifies within 1–6 weeks of starting the medication. Its effect lasts about 24 hours.
  • Guanfacine is an alpha-2A-adrenergic receptor agonist but its action is noradrenaline-mediated and intensifies in 1–3 weeks. Its effect lasts about 24 hours. For safety reasons, the drug should be withdrawn by reducing the dose gradually if it exceeds 3 mg/day.
• Psychostimulants can be paused; for atomoxetine and guanfacine this is not recommended.
  • Routine medication breaks are not required even in psychostimulant medication, especially if, during such a break, symptoms considerably impair functional capacity.
• Medication is usually started with methylphenidate [Evidence Level: C]; there are products with different durations of action and drug release profiles available.
  • The product should be chosen based on the duration of action and the maximum desired effect.
  • In adults particularly, the compatibility of the medication with any other medication the patient may be taking should be assessed. Atomoxetine in particular has interactions, and depending on the patient’s CYP2D6 genotype there may be considerable variation in the dose of atomoxetine required.
  • Pharmacotherapy should be started at low doses which are increased depending on the response and any adverse effects so as to achieve sufficient efficacy without significant adverse effects. The dose should be increased gradually towards the maximum dose until there is no more increase in efficacy or adverse effects prevent further increase. Notice that the effect of intermediate-acting drugs does not last to the evening, and consequently it may be difficult for, for example, the parents to assess the effect of the medication, and an assessment by the teacher is needed.
  • Frequent monitoring and adjustment of dosage, perhaps as often as once a week, are needed in the beginning of pharmacological treatment. Once a suitable dosage has been found, the monitoring takes place at longer intervals. Later, after a possible medication break, the medication may be continued directly with an earlier dosage that is known to be effective.
  • If the first product tried does not produce the desired response even at sufficiently high doses, it may be appropriate to try another methylphenidate product with a different profile, and subsequently change to either lisdexamfetamine, atomoxetine or, in minors dextroamphetamine[Evidence Level: B] or guanfacine (see flowchart in (ADHD drug therapy)).
    • Not all medicines are indicated for the treatment of adult ADHD.
    • Check also local reimbursement policies. Reimbursement of some drugs may require that methylphenidate has been tried first without sufficient effect or that it is otherwise not suitable for the patient.
  • Once a suitable product and dose have been found, follow-up visits should take place every 3 to 12 months to assess the patient's overall mental and physical state, treatment response, need for medication and sufficiency of dosage. Routine breaks in medication are not absolutely necessary but they are useful for assessment.
  • During medication, children's growth rate (weight and height assessed on growth curves) and all patients' pulse rate and blood pressure, as well as any adverse effects, should be monitored regularly. In children, the sufficiency of the dose should be assessed as the child grows (with methylphenidate, a response is often achieved at a dose of about 1 mg/kg/day).
    • If there is loss of appetite or changes in pharmacotherapy, monitoring can be more frequent.
    • Once the growth has ended in adolescents, it is sufficient, as considered appropriate, to monitor weight; i.e. if the adolescent perceives that his/her appetite is good and the patient does not seem to lose weight, there is no special need for regular follow-up measurements.
    • Blood pressure and heart rate should be measured before and during medication. If no significant change is observed, it is sufficient to measure these whenever the dosage or drug is changed, or if the adolescent has symptoms, that could represent adverse effects, such as heart palpitations. In a stable situation, a check-up appointment once or twice a year is sufficient. In adults, more frequent self-monitoring of blood pressure and pulse may be required considering that the risks of somatic diseases increase with age.
• The most common adverse effects of stimulants and atomoxetine are reduced appetite, headaches, various kinds of mild abdominal discomfort, behavioural symptoms (irritability, aggressiveness) and sleeping problems [Evidence Level: B]. Slightly increased pulse rates and elevated blood pressure are common . These are normally insignificant in the treatment of people with good cardiovascular health. Monitoring of blood pressure is important particularly in the beginning of pharmacological treatment and in association with any increase in dosage. Fatigue, hypotension, bradycardia, dizziness, a fainting tendency and weight increase may occur as adverse effects of guanfacine. In addition, guanfacine may lengthen the QT interval.
  • If mild adverse effects occur, try adjusting the dosage or the time of drug administration or changing the product.
  • If severe or serious adverse effects occur, or if mild adverse effects are not reduced by adjusting the dosage, the drug is discontinued.
  • If adverse effects occur, it is useful to ask adolescents and adults in particular about the regularity of their diet and the use of caffeine. Cutting down on excessive concomitant use of caffeine products may sometimes improve the tolerability of medical stimulants.
    • Excessive consumption of sweet or salty liquorice may elevate blood pressure (even in the absence of ADHD medication).
• In some children and adolescents, the need for pharmacological treatment will decrease with time but some will need such treatment even as adults.Pharmacological treatment may also become necessary only in adulthood.
• Pharmacotherapy is usually combined with other forms of treatment.
  • Multifaceted treatment considering any other disorders affecting the symptoms or the treatment is recommended also for adults.
• There is a risk of misuse associated with pharmacological treatment of ADHD that is often associated with intoxicant abuse and an antisocial tendency. Pharmacotherapy for ADHD does not cause dependence or increase the risk of substance use disorder.
  • Pharmacological treatment of any person with substance use disorder and diagnosed ADHD must be followed up extremely strictly at a unit specialized in the treatment of substance use disorder and ADHD or such a unit should be consulted. The suitability and safety of medication must be assessed case by case. Psychosocial treatments may also be useful in the treatment of substance use disorder.
  • In people who misuse alcohol and have ADHD, atomoxetine may be useful in reducing ADHD symptoms but it will not affect alcohol consumption.
  • ADHD medication is also used in so-called student doping but it does not affect the cognitive performance of healthy persons significantly.

Other forms of treatment

• Polyunsaturated fatty acids are ineffective in the treatment of ADHD in children and adolescents, and their use is not recommended.
• Mindfulness methods may be useful in controlling ADHD symptoms.
• Regular aerobic physical exercise may reduce essential symptoms of ADHD in children and adolescents.
• Computerized training of cognitive skills does not appear to affect ADHD symptoms.

• Preliminary examination for suspected ADHD and introduction of support measures fall within the remit of primary health care in all age groups. This is natural particularly in children because age-group-specific health checks collect data on the child’s functional ability and life situation.
• In school-aged children also a drug treatment trial may be carried out within primary health care.
• Check local treatment chains. In many places, a treatment chain has been defined or other agreement made concerning the division of tasks and cooperation between primary health care and specialized care. If not otherwise agreed, a referral should be made to specialized care as follows:
  • to a child psychiatrist or an adolescent psychiatrist if the child's symptoms include significant or worsening mental symptoms or significant problems in child-parent interaction;
  • to an adolescent psychiatrist if the adolescent's symptoms include significant or worsening mental symptoms, severe behavioural problems or a substance-related disorder;
  • to a child neurologist if the child or adolescent is suspected of having a neurological disorder (e.g. neurofibromatosis, epilepsy) or intellectual disability.
  • to an adult psychiatrist if the adult has concomitant moderately severe to severe psychiatric or neuropsychiatric disorders, differential diagnosis is difficult or there are special somatic issues.
• Differential diagnostic examinations of patients with comorbidities or severe symptoms, any further examinations needed, starting of more demanding pharmacological treatment, planning of the treatment and rehabilitation of such patients and making of agreements on further treatment and follow-up fall under the responsibility of specialized care.