Table 10 Practice recommendations for children and adults with comorbid ADHD and ASD: pharmacological interventions

1. In children, pharmacological intervention should be preceded by behavioural observation and psychological intervention as first-line treatment.

2. If psychological/environmental interventions fail in children, then ADHD medication may be helpful for treating symptoms of inattention, hyperactivity, impulsivity, aggression, irritability and emotional lability.

3. Adults are often prescribed medication prior to psychological interventions, as these may be less commonly available.

4. Official guidelines (e.g. NICE) should be followed for the pharmacological treatment of ADHD and ASD as separate conditions. There are no recommended pharmacological treatments for core symptoms of ASD per se.

5. Second-generation antipsychotics may be used with caution for the short-term treatment of irritability in children and adolescents with ASD, although behavioural and environmental interventions are first-line treatments.

6. Given the high rates of comorbidity associated with both ADHD and ASD, medication should be considered to treat comorbid conditions such as anxiety, mood problems and sleep disturbance.

7. Close attention should be paid to side effects of any pharmacological treatment due to the increased likelihood of their occurrence in this group.

8. A ‘low and slow’ approach to titration should be adopted as people with both conditions may be more treatment resistant and more sensitive to the effects of medication (especially with respect to side effects). Medication should be given for the shortest time possible and monitored carefully for the duration of treatment.

9. Good lines of communication should be established between school and child psychiatric/paediatric services (as appropriate) for purposes of monitoring treatment effect in educational settings.

10. Due to sensory issues and physical difficulties, individuals with ASD may be unable to consume medications in tablet form (e.g. difficulty swallowing, aversion to tablets). In this case, liquid preparations should be prescribed.

11. A cautious approach should be taken when prescribing stimulant medications to older adults or other individuals with a history of cardiac problems.

12. Pharmacological treatment is not advised for women with ADHD and ASD during pregnancy.

13. With individuals for whom informed consent may be an issue, the use of adapted behavioural observation and reporting tools such as visual representations or visual analogue scales may be helpful.

14. Clear goals and outcome measures should be specified and monitored to determine the effectiveness of medications prescribed. The reporting tools described above may also be helpful for individuals who have difficulty identifying or describing their thoughts, feelings and sensations in order to facilitate subjective reports of treatment outcome and side effects.

15. All treatment information should be documented in a medication management plan for integration with a bespoke collaborative care plan for the individual, including a Positive Behavioural Support plan to ensure consistency of interventions (including educational) between different caregivers, staff and service-user(s). The care plan should be shared with all relevant parties, with appropriate consent.