What is the first line treatment for Attention Deficit Hyperactivity Disorder (ADHD) in children?

First-Line Treatment for ADHD in Children

For children with ADHD, the first-line treatment varies by age: behavioral therapy for preschoolers (4-5 years) and FDA-approved medications (preferably stimulants) with behavioral therapy for school-aged children (6-11 years). 1

Age-Specific Treatment Recommendations

Preschool-Aged Children (4-5 years)

• Evidence-based parent- and/or teacher-administered behavioral therapy is the first-line treatment for preschoolers 1
• Methylphenidate may be considered only if behavioral interventions don't provide significant improvement and there is moderate-to-severe continuing functional impairment 1
• When considering medication for preschoolers, clinicians should weigh the risks of starting medication at an early age against the harm of delaying effective treatment 1
• Criteria for medication consideration in preschoolers include symptoms persisting for at least 9 months, dysfunction in multiple settings, and inadequate response to behavioral therapy 1

Elementary School-Aged Children (6-11 years)

• FDA-approved medications for ADHD, particularly stimulants, along with behavioral interventions (both parent training and classroom interventions) are recommended as first-line treatment 1
• The evidence is strongest for stimulant medications, followed by atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order) 1
• Educational interventions and individualized instructional supports are necessary components of any treatment plan 1

Adolescents (12-18 years)

• FDA-approved medications for ADHD with the adolescent's assent are the first-line treatment 1
• Behavioral therapy may be prescribed as an adjunctive treatment 1
• Special consideration should be given to medication coverage for symptom control while driving due to increased risk of crashes and motor vehicle violations 1

Medication Options

Stimulants

• Stimulants have the strongest evidence base and largest effect sizes for reducing ADHD core symptoms 1, 2
• Methylphenidate is the most commonly used stimulant with significant reduction in ADHD symptoms both at home and school 1, 2
• Available in immediate-release and various extended-release formulations 1
• Common side effects include decreased appetite, sleep disturbances, increased blood pressure and pulse, and headaches 1

Non-stimulants

• Atomoxetine, extended-release guanfacine, and extended-release clonidine are FDA-approved alternatives 1, 3
• May be considered when stimulants are contraindicated, poorly tolerated, or ineffective 1, 3
• Non-stimulants generally have smaller effect sizes compared to stimulants but provide "around-the-clock" effects 1
• May be particularly useful in cases with comorbid conditions such as tics, sleep disorders, or substance use disorders 1, 3

Behavioral Interventions

• Behavioral parent training has shown a median effect size of 0.55 for improving compliance with parental commands 1
• Behavioral classroom management has demonstrated a median effect size of 0.61 for improving attention to instruction and decreasing disruptive behavior 1
• Beginning treatment with behavioral intervention has been shown to produce better outcomes than beginning with medication in some studies 4
• Combined treatments (behavioral management and medication) represent the gold standard in ADHD treatment 5, 6

Important Considerations

• Treatment should be titrated to achieve maximum benefit with minimum adverse effects 1
• Family preference is essential in determining the treatment plan and enhancing adherence 1
• The school environment, program, or placement is a crucial part of any treatment plan 1
• Regular monitoring for adverse effects and treatment response is necessary 1
• For children with inattention or hyperactivity/impulsivity that doesn't meet full ADHD criteria, psychosocial treatments may be appropriate 1