HOW TO TREAT ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) 2025

HOW TO TREAT ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 30

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 30

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)

I. DEFINITION  

ADHD is a common disorder in child psychiatry, typically characterized by a combination of inattention and hyperactivity. Its hallmark is an inability to sustain necessary focus on a single object, topic, or task, with attention frequently shifting to surrounding stimuli. This results in excessive motor activity, where individuals are constantly active but unable to complete assigned tasks. Diagnosis requires symptoms to persist across multiple settings (e.g., home, school), not just one specific environment. Prevalence is 3-7% among school-aged children, with a male-to-female ratio of 2.5-5.6.

I. ETIOLOGY  

The precise cause of ADHD remains unknown, but several contributing factors are identified:  

1. Genetics:  

   – In identical twins, if one is affected, the other has an 80-90% risk.  

   – Parental ADHD increases offspring risk to ~50%; sibling risk is 15-25%.  

2. Environmental Factors:  

   – Prenatal exposure to lead, pesticides, tobacco, alcohol, or drugs is linked to 10-15% of cases.  

3. Brain Abnormalities/Injuries:  

   – Higher rates in children with encephalitis, meningitis, birth-related brain trauma, postnatal asphyxia, or prematurity.

III. DIAGNOSIS  

1. Clinical Features  

ADHD centers on three symptom clusters:  

– Inattention: Difficulty sustaining focus, frequent careless errors, forgetfulness, losing items, disorganization, avoidance of tasks requiring concentration.  

– Hyperactivity: Restlessness, fidgeting, leaving seats inappropriately, excessive running/climbing, inability to play quietly, relentless activity.  

– Impulsivity: Blurting answers, difficulty waiting turns, interrupting, excessive talking.  

– Severity varies; some struggle with task completion and memory, while others are hyperactive and impulsive.  

– Learning difficulties stem from inattention/hyperactivity, not lack of intelligence.  

– Symptoms evolve: 40-70% persist into adolescence, with a significant proportion continuing into adulthood.

2. Ancillary Testing  

– Routine Tests: Complete blood count, biochemistry, urinalysis, ECG, abdominal ultrasound, chest X-ray.  

– ADHD-Specific Assessment: Vanderbilt scale.  

– Comorbidity Assessments: Intellectual development (WISC, Raven, Denver), autism (CARS, ADOS-G, M-CHAT), behavior (CBCL).  

– Specialized Tests: Metabolic/genetic screening, EEG, CT/MRI brain.

3. Definitive Diagnosis (ICD-10)  

Criterion 1:  

– Inattention (≥6 symptoms for ≥6 months):  

  – Fails to notice details, makes careless mistakes in school/work/activities.  

  – Struggles to sustain attention in tasks/play.  

  – Appears distracted during conversations.  

  – Doesn’t follow instructions, fails to complete tasks (not due to defiance/misunderstanding).  

  – Difficulty organizing tasks/activities.  

  – Avoids/reluctantly engages in tasks requiring focus (e.g., homework).  

  – Loses essential items (e.g., books, pens).  

  – Easily distracted by external stimuli.  

  – Forgetful in daily routines.  

– Hyperactivity (≥3 symptoms for ≥6 months):  

  – Fidgets or squirms excessively.  

  – Leaves seat when expected to remain seated.  

  – Runs/climbs inappropriately (in teens/adults, restlessness).  

  – Struggles with rule-based play/quiet activities.  

  – Constantly active, tireless.  

– Impulsivity (≥1 symptom for ≥6 months):  

  – Answers before questions are completed.  

  – Difficulty waiting turns.  

  – Interrupts/imposes on others.  

  – Talks excessively.  

– Symptoms impair adaptation and harmony compared to peers.  

Criterion 2: Onset before age 7.  

Criterion 3: Symptoms present across multiple settings (e.g., home and school), confirmed by diverse sources.  

Criterion 4: Inattention/impulsivity significantly impairs social, academic, or occupational functioning.  

Criterion 5: Excludes pervasive developmental disorders, mania, depression, or anxiety as sole explanations.

4. Differential Diagnosis  

– Bipolar Disorder (I/II): Cyclic, with depressive phases.  

– Schizophrenia: Later onset, autistic-like symptoms, less typical harmony deficits.  

– Tic Disorders: Stereotyped motor/vocal disturbances.  

– Oppositional Defiant Disorder: Behavioral defiance without core ADHD features.

IV. TREATMENT  

1. Treatment Principles  

– Primarily pharmacotherapy, combined with psychosocial interventions.

2. Treatment Framework  

– Stimulants (First-Line): Methylphenidate, Dextroamphetamine. Controlled substances requiring strict monitoring.  

  – Dosage: Methylphenidate 18-72 mg/day (age-dependent); ECG prior to initiation.  

– Atomoxetine (First-Line Non-Stimulant): Norepinephrine reuptake inhibitor, for ages >6.  

  – Dosage: Start 0.5 mg/kg/day (1 week), increase weekly to maintenance ~1.2 mg/kg/day (max 100 mg/day); reduce 50-75% in hepatic impairment.  

– Antidepressants (Second-Line): For resistance to stimulants/Atomoxetine or co-occurring depression/anxiety: Amitriptyline, Imipramine, Sertraline, Paroxetine, Fluoxetine, Fluvoxamine, Citalopram, Escitalopram, Venlafaxine, Mirtazapine.  

– Anxiolytics: Benzodiazepines for rapid anxiety relief; non-benzodiazepines (e.g., Etifoxine, Zopiclone, Sedanxio) as alternatives.  

– Antipsychotics: Risperidone (0.5-2 mg/day), Olanzapine (1-5 mg/day), Quetiapine for severe agitation.  

– Clonidine (Third-Line): Alpha-adrenergic agonist for co-occurring tics, Tourette’s, or aggression.  

  – Dosage: Start 0.025-0.05 mg/day (split twice daily), increase 0.025-0.05 mg every 3-7 days to 0.1-0.25 mg/day.  

– Anticonvulsants: For behavioral/emotional symptoms or epilepsy:  

  – Valproate (30-50 mg/kg/day), Carbamazepine (15-20 mg/kg/day), Phenobarbital (3-6 mg/kg/day), Oxcarbazepine (30-46 mg/kg/day), Gabapentin (25-50 mg/kg/day), Lamotrigine (5-15 mg/kg/day), Levetiracetam (40-100 mg/kg/day).  

– Supportive: Neuroprotectants (piracetam, ginkgo biloba, vinpocetine, choline alfoscerate, nicergoline), liver support, cognitive enhancers, nutrition (B vitamins, minerals, digestible diet, IV nutrition if needed).

V. PROGNOSIS AND COMPLICATIONS  

– 40-70% persist into adolescence, with symptom reduction often starting ages 12-20; ~50% persist into adulthood.  

– Hyperactivity tends to decrease with age, but inattention improves less.  

– Increased risk of antisocial personality disorder, substance use, depression, and anxiety.

VI. PREVENTION  

– Challenging due to unclear etiology and genetic factors, but risk reduction includes:  

  – Optimal maternal care and safe childbirth.  

  – Preventing brain-damaging illnesses.  

  – Avoiding smoking, alcohol, or drugs during pregnancy.

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