What are the recommended tools and medications for Attention Deficit Hyperactivity Disorder (ADHD) screening and treatment?

ADHD Screening Tools and Treatment

For ADHD screening and diagnosis, clinicians should use standardized behavior rating scales and follow DSM criteria, while FDA-approved medications (particularly stimulants) are the first-line treatment for most age groups, with behavior therapy as an important complementary approach. 1

Diagnostic Tools for ADHD

Recommended Screening Tools

• Behavior Rating Scales: These remain the standard of care for assessing diagnostic criteria for ADHD 1
  • Conners Rating Scales: Widely used with good psychometric properties for assessing ADHD symptoms and related problems 2
  • Adult ADHD Self-Report Scale: Recommended for adult ADHD assessment 3
  • Conners Adult ADHD Rating Scales: Useful for symptom and function assessment in adults 3

Diagnostic Criteria Requirements

• DSM Criteria: Diagnosis must be based on meeting DSM criteria with documentation of impairment in more than one major setting 1
• Symptom Requirements:
  • Inattentive Type: At least 6 symptoms persisting for 6+ months (lack of attention to details, poor sustained attention, etc.) 4
  • Hyperactive-Impulsive Type: At least 6 symptoms persisting for 6+ months (fidgeting, leaving seat, excessive talking, etc.) 4
  • Combined Type: Must meet criteria for both inattentive and hyperactive-impulsive types 4

Assessment Process

• Multiple Information Sources: Gather information from parents/guardians, teachers, and other school/mental health clinicians 1
• Rule Out Alternative Causes: Differential diagnosis must exclude other conditions that might explain symptoms 1
• Assess for Co-occurring Conditions: Evaluate for emotional/behavioral disorders, developmental disorders, and physical conditions 1

Treatment Recommendations

Pharmacological Treatment

Children and Adolescents

1. Ages 4-5 years:

   • Behavior therapy is first-line treatment 1
   • If behavior therapy alone is insufficient, methylphenidate may be prescribed 1

2. Ages 6-11 years:

   • FDA-approved medications (strong recommendation) 1
   • Evidence-based parent/teacher-administered behavior therapy 1
   • Preferably both medication and behavior therapy together 1

3. Ages 12-18 years:

   • FDA-approved medications with adolescent assent (strong recommendation) 1
   • Behavior therapy may be prescribed (recommendation) 1
   • Combination of both is preferable 1

Adults

• Stimulants (amphetamine and methylphenidate) are first-line pharmacotherapy 3
• For adults unable to take stimulants or with concurrent anxiety/depression, options include:
  • Atomoxetine
  • Viloxazine
  • Bupropion 3

Medication Efficacy and Selection

Stimulants

• Highest Efficacy: Effect size approximately 1.0 1
• First-line Options:
  • Methylphenidate formulations
  • Amphetamine formulations 1, 3

Non-stimulants (slightly weaker effects, effect size ~0.7)

1. Atomoxetine:

   • FDA-approved for ADHD 4
   • Good option for patients with substance use disorders due to low abuse potential 5
   • Can address both ADHD and depression symptoms 5

2. Extended-release guanfacine

3. Extended-release clonidine 1

Medication Dosing Guidelines

Atomoxetine

• Children/adolescents up to 70 kg: Initial dose 0.5 mg/kg/day, target 1.2 mg/kg/day 5, 4
• Adults/children over 70 kg: Initial dose 40 mg/day, maximum 100 mg/day 5
• Hepatic Impairment Adjustments:
  • Moderate impairment: Reduce to 50% of normal dose
  • Severe impairment: Reduce to 25% of normal dose 5

Stimulants

• Methylphenidate: Start at 5 mg twice daily, titrate by 5-10 mg weekly, maximum 60 mg daily 5
• Amphetamine-based: Start at 2.5 mg once or twice daily, gradual titration, maximum typically 20-30 mg daily 5

Non-Pharmacological Interventions

• Cognitive Behavioral Therapy (CBT): Most effective psychotherapy for adult ADHD, especially when combined with medication 5
• Mindfulness-Based Interventions: Help with inattention symptoms, emotion regulation, and executive function 5
• Psychoeducation: Decreases disorganization and inattention, increases self-confidence 5

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks after initiating treatment 5
• Monitor vital signs, particularly blood pressure and heart rate 5
• Assess for side effects including insomnia, appetite changes, and mood effects 5
• Regular follow-up to evaluate functional improvement across settings 5

Managing Common Side Effects

• Insomnia: Consider earlier dosing of stimulant or reducing afternoon/evening doses 5
• Appetite Suppression: Encourage meals when medication effect is lowest; provide high-calorie snacks in evening 5
• Rebound Irritability: Overlap stimulant dosing or use extended-release formulations 5
• Growth Effects: Monitor height and weight; effects typically 1-2 cm reduction in growth velocity 1

Cautions and Contraindications

• Stimulants: Not ideal for patients with substance dependence history 5
• Cardiovascular Risk: Rare occurrence of sudden cardiac death; assess cardiac symptoms 1
• Psychiatric Effects: Monitor for hallucinations or psychotic symptoms with stimulants 1
• Suicidal Ideation: Atomoxetine carries warning for increased risk in children/adolescents; monitor closely 4

ADHD treatment should be considered part of a comprehensive treatment program that may include psychological, educational, and social interventions 4.