What is the recommended treatment for Attention Deficit Hyperactivity Disorder (ADHD)?

Recommended Treatment for Attention Deficit Hyperactivity Disorder (ADHD)

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

Pharmacological Treatment

Stimulant Medications

• First-line pharmacological treatment with strong recommendation (Grade A) 1
• Dosing recommendations:
  • For children/adolescents ≤70 kg: Start methylphenidate at 5 mg twice daily (immediate-release) or 10 mg once daily (extended-release); maximum 1.0 mg/kg/day 1
  • For amphetamine formulations: Start 5-10 mg daily; maximum 50 mg daily 1
  • For children/adolescents >70 kg and adults: Follow adult dosing guidelines 1

Non-Stimulant Medications

• Atomoxetine (Strattera): Alternative when stimulants are contraindicated or ineffective
  • Children/adolescents ≤70 kg: Start at 0.5 mg/kg/day, target dose 1.2 mg/kg/day 2
  • Children/adolescents >70 kg and adults: Start at 40 mg/day, target dose 80 mg/day, maximum 100 mg/day 2
  • Monitor liver function as atomoxetine has been associated with rare cases of liver injury 1
• Alpha-2 adrenergic agonists (Guanfacine, Clonidine):
  • Can be used as monotherapy or adjunctive therapy with stimulants 1
  • Minimal effects on appetite compared to stimulants 1
  • Guanfacine typical dosing range: 1-7 mg/day 1

Age-Specific Treatment Approaches

Preschool Children

• Behavioral interventions should be tried first 1
• Medication only if significant impairment persists despite behavioral interventions 1

School-Age Children

• Combined behavioral and medication approach recommended 1
• Educational supports including IEPs or 504 plans essential 1
• Classroom accommodations (preferential seating, modified work assignments) 1

Adolescents

• Combined approach similar to school-age children 1
• Assess substance use risk before prescribing stimulants 1
• Consider cognitive-behavioral therapy (CBT) approaches 3

Adults

• Screen for underlying cardiovascular disease before prescribing stimulants 1
• Cognitive-behavioral therapy is the most effective psychological treatment for ADHD symptoms in adults 4
• Structured, skills-based psychosocial interventions for adults with residual symptoms 5

Behavioral/Psychosocial Interventions

• Parent Training in Behavior Management (PTBM) for children 1
• Behavioral classroom interventions for school-age children 1
• Cognitive Behavioral Therapy (CBT) for adolescents and adults 4, 6
• Skills training in organization and planning strategies 5

Monitoring and Follow-up

• Regular assessment of symptom control 1
• Weight monitoring at each follow-up appointment 1
• Vital signs checks: annually in children, quarterly in adults 1
• Screen for cardiac risk factors before prescribing stimulants 1
• Periodically reevaluate long-term medication usefulness 2

Common Pitfalls to Avoid

• Inadequate medication titration reducing treatment effectiveness 1
• Relying solely on medication instead of combined approaches 1
• Discontinuing treatment prematurely 1
• Overlooking comorbid conditions (anxiety, depression) 1
• Ignoring educational needs as part of comprehensive treatment 1
• Failing to screen for bipolar disorder before starting atomoxetine 2

Special Considerations

• Adjust atomoxetine dosing for hepatically impaired patients:
  • Moderate impairment: Reduce to 50% of normal dose
  • Severe impairment: Reduce to 25% of normal dose 2
• For patients taking strong CYP2D6 inhibitors or who are CYP2D6 poor metabolizers, adjust dosing accordingly 2
• Monitor for suicidal ideation in children and adolescents starting atomoxetine 2

The comprehensive treatment approach should address symptoms across different settings (home, school, work) and target functional impairments specific to the individual's ADHD presentation.