What is the current management of Attention Deficit Hyperactivity Disorder (ADHD)?

Current Management of Attention Deficit Hyperactivity Disorder (ADHD)

The current management of ADHD requires a comprehensive treatment approach that includes FDA-approved medications combined with parent training in behavior management (PTBM) and behavioral classroom interventions, with educational accommodations as necessary components of the treatment plan. 1, 2

Diagnosis and Assessment

ADHD is diagnosed based on DSM-5 criteria requiring:

• For Inattentive Type: At least 6 symptoms of inattention persisting for at least 6 months
• For Hyperactive-Impulsive Type: At least 6 symptoms of hyperactivity/impulsivity persisting for at least 6 months
• For Combined Type: Meeting criteria for both inattentive and hyperactive-impulsive types 3

Age-Specific Treatment Recommendations

For Preschool Children (4-5 years)

• First-line treatment: Parent Training in Behavior Management (PTBM) with strong evidence (Grade A recommendation) 1, 2
• Medication should be considered only if behavioral interventions fail to provide significant improvement 1
• If medication is needed, methylphenidate may be considered, though with careful monitoring due to higher rates of adverse effects in this age group 1

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

• Recommended treatment: FDA-approved medications for ADHD combined with PTBM and behavioral classroom interventions 1
• Stimulant medications have the strongest evidence (effect size 1.0) 2
• Non-stimulants like atomoxetine have moderate evidence (effect size 0.7) 2
• Educational interventions and individualized instructional supports are necessary components 1

For Adolescents (12-18 years)

• Recommended treatment: FDA-approved medications with the adolescent's assent 1
• Evidence-based training interventions and behavioral interventions are encouraged alongside medication 1
• Special attention should be given to medication coverage for symptom control while driving 1

Medication Management

Stimulant Medications

• First-line pharmacological treatment with strongest evidence 2
• Methylphenidate starting dose: 5 mg twice daily (immediate-release) or 10 mg once daily (extended-release); maximum 1.0 mg/kg/day 2
• Amphetamine starting dose: 5-10 mg daily; maximum 50 mg daily 2

Non-Stimulant Medications

• Atomoxetine:
  • For children up to 70 kg: Initial dose 0.5 mg/kg/day, target dose 1.2 mg/kg/day 3
  • For children over 70 kg and adults: Initial dose 40 mg/day, target dose 80 mg/day, maximum 100 mg/day 3
• Extended-release guanfacine can be used as adjunctive therapy when monotherapy is insufficient 2

Behavioral Interventions

Parent Training in Behavior Management (PTBM)

• Essential component for all age groups 1, 2
• Involves training parents in specific techniques to:
  • Provide rewards for desired behavior (positive reinforcement)
  • Use planned ignoring for minor inappropriate behaviors
  • Provide appropriate consequences for undesired behaviors 1
  • Consistently apply rewards and consequences 1

School-Based Interventions

• Two categories of school-based services 1:
  1. Interventions to improve skills: Daily report cards, training interventions, point systems, academic remediation
  2. Accommodations: Extended time for tests/assignments, reduced homework, keeping study materials in class, teacher's notes provision

Combined Treatment Approach

The combination of medication management and behavioral therapy offers several advantages:

• Allows for lower stimulant dosages, potentially reducing adverse effects 1
• Provides greater improvements on academic and conduct measures, especially when ADHD is comorbid with anxiety or in lower socioeconomic environments 1
• Results in higher satisfaction among parents and teachers 1
• May be superior to medication alone for non-ADHD symptoms and positive functioning outcomes 4

Treatment of Comorbid Conditions

• Some comorbid conditions may improve with ADHD treatment alone 1
• Others may require specific additional treatments 1
• For comorbid bipolar disorder, mood symptoms should be stabilized with mood stabilizers before considering stimulants for residual ADHD symptoms 2
• Screen for bipolar disorder prior to starting medications like atomoxetine 3

Monitoring and Follow-up

• Regular monitoring every 3-4 weeks during dose titration 2
• Once stabilized, follow-up every 3-6 months 2
• Monitor parameters including appetite, weight, sleep disturbances, mood changes, and growth 2
• ADHD should be treated as a chronic condition requiring ongoing management 1

Common Pitfalls to Avoid

• Failing to recognize ADHD as a chronic condition requiring ongoing management 2
• Overlooking comorbid conditions that can worsen symptoms 2
• Treating only ADHD symptoms while neglecting anxiety or depression 2
• Using medication for children whose symptoms do not meet full DSM-5 criteria for ADHD 1
• Providing accommodations without interventions aimed at improving skills, which may lead to reduced expectations long-term 1

Recent research supports a psychosocial-first approach, particularly for complex ADHD cases, with medication added as necessary 5, 6. This sequencing may produce better outcomes overall than beginning treatment with medication alone 6.