What are the recommended treatments for Attention Deficit Hyperactivity Disorder (ADHD)?

Recommended Treatments for Attention Deficit Hyperactivity Disorder (ADHD)

The recommended first-line treatment for ADHD is a combination of FDA-approved medications along with behavioral interventions, with specific approaches tailored by age group. 1

Treatment Recommendations by Age Group

Elementary and Middle School-Aged Children (6-12 years)

1. FDA-approved medications (Grade A strong recommendation)

   • Stimulants (methylphenidate, amphetamine-based medications)
     • Methylphenidate: Start 5mg twice daily (immediate-release) or 10mg once daily (extended-release); maximum 1.0mg/kg/day 2
     • Amphetamine/Adderall: Start 5-10mg daily; maximum 50mg daily 2

2. Behavioral interventions (Grade A strong recommendation)

   • Parent Training in Behavior Management (PTBM)
   • Behavioral classroom interventions
   • Preferably both PTBM and classroom interventions together

3. Educational supports

   • Individualized Education Program (IEP) or 504 rehabilitation plan
   • Classroom accommodations (preferential seating, modified assignments)

Adolescents (12-18 years)

1. FDA-approved medications with adolescent's assent (Grade A strong recommendation)

   • Same medication options as for younger children
   • Consider risk of substance use before prescribing stimulants 2

2. Evidence-based training and behavioral interventions

   • Cognitive Behavioral Therapy (CBT)
   • Educational and instructional supports

Adults

1. FDA-approved medications

   • Stimulants (first-line)
   • Non-stimulants (atomoxetine, guanfacine, clonidine)

2. Cognitive Behavioral Therapy

   • Particularly effective when combined with medication 3, 4
   • Improves core ADHD symptoms, executive function, and quality of life 3
   • Helps address residual symptoms after medication optimization 5

Medication Options

Stimulant Medications

• First-line pharmacological treatment 1, 6
• Most effective for immediate reduction of core ADHD symptoms
• Common side effects: appetite suppression (20-56% of children), sleep disturbances 2

Non-Stimulant Medications

1. Atomoxetine (Strattera)

   • Dosing for children/adolescents ≤70kg: Start at 0.5mg/kg/day, target 1.2mg/kg/day 7
   • Dosing for individuals >70kg: Start at 40mg/day, target 80mg/day, maximum 100mg/day 7
   • Alternative for patients who don't respond to or can't tolerate stimulants (10-30% of cases) 6
   • Requires 2-4 weeks to reach full effectiveness

2. Alpha-2 adrenergic agonists (Guanfacine, Clonidine)

   • Minimal effects on appetite compared to stimulants 2
   • Guanfacine dosing range: 1-7mg/day or 0.05-0.12mg/kg/day 2
   • Can be used as monotherapy or adjunctive therapy with stimulants

Behavioral and Psychosocial Interventions

For Children and Adolescents

• Behavioral parent training and classroom interventions are well-established treatments 1
• Parents often report higher satisfaction with behavioral therapy than with medication alone 1
• Positive effects of behavioral therapy tend to persist after treatment ends, unlike medication 1

For Adults

• CBT shows significant benefits when combined with medication 3, 4, 8
• Internet-based CBT (iCBT) is effective and improves accessibility 3
• CBT helps with:
  • Core ADHD symptoms (moderate to large effect size) 4
  • Executive functioning 3
  • Secondary issues like anxiety and depression (small to moderate effect size) 4, 8
  • Quality of life 3

Monitoring and Follow-up

1. Regular assessment of symptom control
2. Medication titration to achieve maximum benefit with tolerable side effects (Grade B strong recommendation) 1
3. Weight monitoring for patients on stimulants 2
4. Vital signs checks: annually in children, quarterly in adults 2
5. Periodic reevaluation of long-term medication usefulness 7

Important Considerations

• ADHD treatment should be part of a comprehensive program that includes psychological, educational, and social interventions 7
• Family and patient preferences are essential in determining the treatment plan and enhancing adherence 1
• Screen for bipolar disorder before starting atomoxetine 7
• For preschool children, behavioral interventions should be tried before medication 2
• Consider cardiac risk factors before prescribing stimulants 2
• Monitor liver function with atomoxetine due to rare cases of liver injury 2

Common Pitfalls to Avoid

1. Inadequate medication titration - The optimal dose is required to reduce core symptoms to levels of children without ADHD 1
2. Relying solely on medication - Combined approaches are more effective than medication alone 3, 4
3. Discontinuing treatment prematurely - ADHD often requires extended treatment periods 7
4. Overlooking comorbid conditions - Anxiety, depression, and other conditions often co-occur with ADHD and may require specific treatment 4, 8
5. Ignoring educational needs - Educational interventions are a necessary part of any treatment plan 1