By Mia Faull

The guidelines are authored by: Brendan Belsham, Linda Kelly, Renata Schoeman

In February 2025, the South African Society of Psychiatrists (SASOP) and the Psychiatry Management Group released updated guidelines for managing attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. As a medical writer and the mother of a child with ADHD, I found several insights particularly helpful – and empowering. This blog post highlights some of the points that may be of particular interest to both parents and healthcare professionals.

Diagnosis of ADHD

The SASOP/PsychMg child and adolescent attention-deficit/hyperactivity disorder guidelines acknowledge that ADHD is a common neurodevelopmental disorder that:

• Is costly
• Is chronic
• Has a significant impact on the quality of life for people with ADHD and their families
• Usually persists into adulthood
• Is highly heritable
• Is often accompanied by a comorbidity

Because ADHD is a common disorder presenting in early childhood, screening should ideally be done in preschool or early primary school. Although this would prevent delayed or missed diagnoses, it’s acknowledged that actually carrying out this screening in the South African context is challenging.

ADHD is often under- or mis-diagnosed, but accurate diagnosis is crucial to the successful management of the disorder. It’s therefore recommended that a diagnosis be made by a specialist healthcare professional, such as a:

• Child psychiatrist
• Paediatric neurologist
• Neurodevelopmental paediatrician

The diagnosis must be based on symptoms listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and, if a child is referred to a specialist, screening for ADHD should take place as part of the psychiatric diagnostic history – regardless of the reason for referral.

How is a diagnosis made?

While screening tools may assist in recognising symptoms, they can’t in and of themselves be used to diagnose ADHD. The clinical interview still remains the main assessment in diagnosing the disorder. The following stakeholders are important in gathering a full clinical and psychosocial history:

• Parents/caregivers
• Child/adolescent
• Teachers/school
• Therapists/other healthcare professionals (occupational therapists, speech therapists, etc.)

ADHD comorbities: common and significant

Something that I was not aware of is how common comorbidities are in children with ADHD:

• 50%–90% of children with ADHD have at least one comorbid condition
• 50% have two or more comorbid conditions

Comorbidity leads to more social, emotional and psychological difficulties. Classified as either current and episodic or lifespan disorders, some of the most frequent comorbid conditions are described below.

Current and episodic conditions

• Disruptive behavioural disorders, e.g. oppositional defiant disorder (ODD) and conduct disorder
• Anxiety disorders, e.g. generalised anxiety disorder and social anxiety
• Mood disorders, e.g. depression and bipolar disorder

Lifespan conditions

• Developmental disorders of language learning and motor development
• Autism spectrum disorder (ASD)
• Intellectual ability

Where comorbidities are concerned, the guidelines advise that the most impairing condition be treated first, although both/all conditions will usually need treatment. Because treatment for one condition may exacerbate symptoms of another, it’s important that the child is carefully monitored and adjustments in treatment are made slowly. Again, it’s highly recommended that comorbidities with ADHD are managed by specialists.

Common ADHD comorbidities

Did you know?

30%–50% of children with ADHD fulfil the criteria for ODD or conduct disorder

Anxiety disorders and depression often co-occur with ADHD, with anxiety disorders seen in 15%–35% of children with ADHD, and depression in 20%–50%.

Tic disorders, such as Tourette syndrome, are commonly comorbid with ADHD too, with 55%–90% prevalence rates.

In 30%–70% of ASD cases, there is a comorbidity with ADHD.

There are two other comorbidities that I think are important to highlight as they may be especially noteworthy for parents.

Sleep disorders

Almost 50% of people with ADHD experience sleep disturbance and there is growing evidence that they may also be more affected by circadian rhythm disruptions than those without ADHD. The guidance is that behavioural sleep interventions and melatonin are considered effective in treating children and adolescents.

I found it helpful to learn that my child was more susceptible to poor sleep due to their ADHD, and that there are possible treatment options to assist with this. When a child doesn’t sleep well, neither do the parents and parenting while tired is all the harder!

Excessive digital media use

The use of digital media among children and teenagers has obviously increased drastically over the last decade. Social media and gaming are both seen as addictive activities and longitudinal studies have revealed that:

• Excessive digital media use (EDMU) is a risk factor in the onset of ADHD symptoms
• There is a bidirectional relationship between EDMU and ADHD as they aggravate each other

In a recent study, 44% of children and teens with ADHD met the criteria for internet gaming disorder compared to 9.5% in controls. 

It’s therefore important for healthcare professionals to educate parents and children about this bidirectional relationship.

We’re currently seeing a move in parenting circles to new awareness around the need to limit screen time, as a result of the Smartphone Free Childhood movements worldwide and Jonathan Haidt’s book The Anxious Generation which speaks broadly to the possible harms of excessive screen time. The harmful effects seem all the more important to note for parents of children with ADHD.

ADHD treatment: options and recommendations

Treatment for ADHD must be individualised, holistic and multidisciplinary and, while medication is seen as the cornerstone of treatment for children and adolescents, psychosocial interventions also play an important role.

I’ve had many discussions with other parents of ADHD children – and can confirm that the topic of medication is a touchy one! Some people are fiercely against it and feel that schools and society should adjust to accommodate the child (and neurodiversity more widely), while others feel that they need to work within the confines they have. I understand the spectrum of feelings; it’s not easy to decide to put your precious child onto schedule 6 psychiatric medication.

The guideline authors highlight that, because ADHD has a big impact on people’s quality of life and their ability to be successful in their education, work and social lives (i.e. its high morbidity), it’s very important for both caregivers and healthcare professionals to seriously consider the risks of not treating a child with ADHD. Untreated ADHD is associated with:

• Decreased social, education and vocational functioning
• Poorer self-care
• Higher rates of accidental injury

Experts therefore agree that the treatment of ADHD with medication is more cost-effective compared to no treatment or behavioural therapy alone.

Interest is rising in pharmacogenetic testing to help determine each patient’s ADHD medication of choice. Since adherence to ADHD medication is often poor – likely due to side effects – the guidelines suggest that it would be helpful if pharmacogenetic studies could assist with identifying which medications are more likely to be tolerated.

What are the recommended pharmacological treatment options?

As is well known in ADHD circles, there are two main types of medication for ADHD treatment:

• Stimulants: methylphenidate (MPH) and amphetamine (AMP)
• Nonstimulants: atomoxetine (ATX), alpha2-adrenoceptor agonists and tricyclic antidepressants

Stimulants

Stimulants are the most widely studied pharmacological treatment for ADHD from childhood through adulthood. Both MPH and AMP have similar response rates of 70%. They are noted to reduce core ADHD symptoms and to improve:

• Defiance
• Academic performance
• Social functioning
• Fine and gross motor functioning

International guidelines mostly recommend one of the stimulant medications as the first-line medication of ADHD treatment. In South Africa, MPH is more likely to be prescribed over AMP because doctors have greater experience with it, and because it’s more widely available in both our public and private health sectors.

Long-acting formulations of stimulants are usually preferred because they reduce the need for multiple doses in a single day and therefore encourage greater treatment adherence, symptom management and treatment response.

Nonstimulants

The guidelines are clear that ATX isn’t as effective as stimulant medication, but that it’s an important alternative for people who may experience significant side effects from stimulants or who don’t respond to stimulants as well as hoped. It can also be helpful for those with comorbid anxiety.

What happens after diagnosis and initiation of pharmacological treatment?

• The child/adolescent should be seen by the prescribing doctor within four to six weeks of starting treatment, to check their response to treatment and to assess the impact of side effects.
• Thereafter, follow-ups are at the doctor or patient’s discretion but can’t be longer than six months apart due to the high schedule classification of the medication.
• Monitoring of treatment efficacy is needed from various stakeholders (parents, child, teachers, etc.) and rating scales can be helpful in this regard.
• It’s generally agreed that treatment interruption (medication holidays) is no longer encouraged.

What are the recommended nonpharmacological treatments?

Psychoeducation is important and should include parents/caregivers and the child, if possible. The topics covered should include:

• ADHD symptoms
• Treatment options
• Possible side effects of medication
• Lifestyle factors such as diet, exercise, screen time and sleep

Behavioural therapy has been shown to be helpful in nurturing stronger well-being in ADHD children and teenagers. Topics include organisational skills, social skills, problem-solving and cognitive restructuring. Studies have demonstrated small effects on academic outcomes, small to medium effects on parenting and medium to large effects on organisational skills.

Mindfulness-based interventions have shown some improvement in ADHD symptoms at six-month follow-up in randomised controlled trials. Other studies have shown positive impact on emotional regulation of children, and not on ADHD symptoms.

Some lifestyle factors of interest

A recent meta-analysis (research that combines the results of multiple independent studies exploring the same topic) shows that exercise improved attention, motor skills and executive function in ADHD children, compared to controls. It’s generally agreed that exercise is beneficial for both physical and cognitive health.

In three other meta-analyses, omega-3 fatty acid supplements have resulted in a small to moderate improvement in ADHD symptoms. Another study showed that children taking omega-3 supplements could have their dose of stimulant medication reduced.

What happens when the ADHD adolescent transitions to adult services?

For most children (65%), ADHD symptoms will continue into adulthood. The guidelines therefore stress the importance of transitional care during this time. Recommendations include:

• Education that ADHD continues into adulthood
• Preparation for the upcoming change in services
• Information about available services
• A period of parallel care (of both child and adult services together)

Final thoughts

While ADHD is a costly and disruptive condition that affects not only the child but their family and caregivers too, I’m grateful my child is growing up in a time when the condition is recognised, researched and increasingly better understood. Access to evidence-based support makes such a difference – but I’m also deeply aware that many families in South Africa face enormous barriers to reaching that support, despite being committed to helping their children thrive. Our team at MediComm is always looking for new and better ways to ensure important medical information reaches those who need it most.

 

I’d like to thank the authors – Brendan Belsham, Linda Kelly and Renata Schoeman – for their world-class guidance and for speaking directly to the South African context.

Click here to download The SASOP/PsychMg child and adolescent attention-deficit/hyperactivity disorder guidelines for more valuable information or read more on the useful websites below:

Dr Brendan Belsham’s website: https://www.drbelsham.com/

Prof. Renata Scheoman’s website: https://renataschoeman.co.za/

ADDitude Magazine offers a multitude of resources about ADHD for parents and professionals: https://www.additudemag.com

The UK NHS’s ADHD in children and young people website: https://www.nhs.uk/conditions/adhd-children-teenagers/

For any medical writing queries, please contact MediComm. We deliver clear, compelling, creative and accurate information across all healthcare spheres.

Reference

Belsham B, Kelly L, Schoeman R. The SASOP/PsychMg child and adolescent attention-deficit/hyperactivity disorder guidelines. South African Journal of Psychiatry. 2025;31(0):12. doi:10.4102/sajpsychiatry.v31i0.2357