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

Recommended Treatments for Attention Deficit Hyperactivity Disorder (ADHD)

For ADHD treatment, FDA-approved medications combined with behavioral therapy is strongly recommended for school-aged children (6-12 years) and adolescents (12-18 years), while behavioral therapy should be the first-line treatment for preschoolers (4-5 years). 1

Age-Based Treatment Recommendations

Preschool Children (4-5 years)

• First-line treatment: Parent/Teacher-administered behavioral therapy 1
• Second-line treatment: Consider methylphenidate if behavioral interventions are insufficient and symptoms are moderate to severe 2
• Caution: Clinicians must weigh the risks of starting medication before age 6 against the harm of delaying treatment 2

School-Age Children (6-12 years)

1. Combination approach:

   • FDA-approved medications for ADHD
   • Parent/Teacher Behavioral Management (PTBM)
   • Behavioral classroom interventions 2, 1

2. Educational interventions are a necessary component:

   • Individualized instructional supports
   • Appropriate school environment adjustments
   • Class placement considerations
   • Often includes an Individualized Education Program (IEP) 2

Adolescents (12-18 years)

1. Primary treatment:

   • FDA-approved medications with the adolescent's assent 2
   • Evidence-based training interventions and behavioral therapy 2, 1

2. Educational supports continue to be important:

   • School accommodations
   • Organizational skills training 1

Medication Options

Stimulant Medications (First-line)

• Methylphenidate formulations (effect size ~1.0)
• Amphetamine formulations (effect size ~1.0)
• Monitoring: Regular assessment of vital signs, weight, and side effects 1, 3

Non-Stimulant Medications (Alternative options)

• Atomoxetine (effect size ~0.7)

  • Warning: Increased risk of suicidal ideation in children/adolescents 3
  • Dosing:
    • Children ≤70kg: Start at 0.5mg/kg/day, target 1.2mg/kg/day
    • Children >70kg and adults: Start at 40mg/day, target 80mg/day 3

• Extended-release guanfacine

• Extended-release clonidine 1

Medication Selection Considerations

• Comorbid conditions: Non-stimulants may be preferred for patients with:
  • Anxiety or depression
  • Substance abuse concerns
  • Tic disorders/Tourette's syndrome 1

Behavioral and Psychosocial Interventions

Parent/Family Training

• Focus on consistent discipline, positive reinforcement, and clear communication
• Most effective when continued over extended periods 1

Cognitive-Behavioral Therapy (CBT)

• Most extensively studied psychotherapy for ADHD
• Focuses on time management, organization, planning, emotional self-regulation
• Most effective when combined with medication 1, 4

Organizational Skills Training

• Helps develop planning, time management, and organizational abilities
• Particularly beneficial for academic functioning 1

Mindfulness-Based Interventions

• Emerging evidence for improvements in:
  • Inattention symptoms
  • Emotion regulation
  • Executive function
  • Overall quality of life 1, 5

Treatment Monitoring and Adjustment

1. Regular assessment of:

   • Treatment efficacy
   • Adverse effects
   • Comorbid conditions 1

2. Medication titration:

   • Adjust to achieve maximum benefit with minimal adverse effects
   • Periodically reevaluate long-term usefulness 1, 3

3. Treatment persistence:

   • Discontinuing treatment can lead to worse outcomes
   • ADHD should be recognized as a chronic condition requiring ongoing management 1

Treatment Sequencing Considerations

Research suggests that beginning treatment with behavioral intervention followed by adding medication if needed may produce better outcomes than starting with medication alone, particularly for:

• Reducing classroom rule violations
• Decreasing out-of-class disciplinary events
• Improving parent attendance at behavioral training sessions 6

Common Pitfalls to Avoid

1. Using medication as sole treatment:

   • Atomoxetine is indicated as part of a total treatment program that includes psychological, educational, and social interventions 3

2. Inadequate monitoring:

   • Regular assessment of side effects, vital signs, weight, and psychiatric symptoms is necessary 1

3. Discontinuing treatment prematurely:

   • Longitudinal studies show greater risk of significant problems if treatment is discontinued 1

4. Overlooking comorbidities:

   • Screen for and address common comorbid conditions such as anxiety, depression, and learning disorders 1

5. Failing to screen for bipolar disorder:

   • Prior to initiating atomoxetine, screen patients for personal or family history of bipolar disorder, mania, or hypomania 3