Treatment of ADHD
For moderate to severe ADHD, the gold standard of treatment involves a combination of psychotherapy and medication, with stimulant medications being the first-line pharmacological option due to their effectiveness in 70-80% of patients with ADHD. 1
Pharmacological Treatment Options
First-Line Medications
- Stimulant medications (methylphenidate and amphetamine-based stimulants) have the strongest evidence for treating ADHD symptoms and are recommended as first-line pharmacological treatment 1, 2
- Stimulant medications should be titrated to achieve maximum benefit with minimum adverse effects, with dosing individualized based on response rather than strictly on a milligram-per-kilogram basis 1
- For children under 70 kg, stimulant dosing typically starts low and is gradually increased to an optimal dose that controls symptoms without adverse effects 1, 3
Non-Stimulant Options
- Atomoxetine, extended-release guanfacine, clonidine, and viloxazine are FDA-approved non-stimulant options for ADHD treatment 1, 3
- Atomoxetine is indicated as an integral part of a total treatment program for ADHD that may include psychological, educational, and social interventions 3
- Non-stimulant medications may be considered for patients who do not respond to stimulants or cannot tolerate their side effects 4
Non-Pharmacological Interventions
Psychoeducation
- Psychoeducation has been shown to decrease disorganization and inattention and increase self-confidence among adults with ADHD 1
- Key topics in psychoeducation include information about the disorder, prevalence, symptoms, risk factors, co-occurring conditions, and treatment options 1
Behavioral Therapy
- For preschool-aged children (4-5 years), behavioral therapy administered by parents and/or teachers is recommended as first-line treatment 1, 5
- For school-aged children (6-12 years), a combination of FDA-approved medications and parent/teacher-administered behavioral therapy is strongly recommended 1, 5
- Behavioral therapy helps parents and school personnel learn effective strategies to manage problematic behaviors like interrupting, aggression, and non-compliance 1, 2
Cognitive Behavioral Therapy (CBT)
- CBT has been extensively studied and found to be the most effective psychotherapy option for adults with ADHD 1, 6
- CBT helps develop executive functioning skills related to time management, organization, planning, emotional self-regulation, and impulse control 1
- The effectiveness of CBT for ADHD is further increased when used in combination with medication 1, 6
Mindfulness-Based Interventions (MBIs)
- Evidence for mindfulness in managing ADHD in adults is increasing, with demonstrated benefits for inattention symptoms, emotion regulation, executive function, and quality of life 1, 7
- MBIs are recommended by various clinical guidelines as non-pharmacological interventions for adults with ADHD 1, 7
Age-Specific Treatment Recommendations
Children (6-12 years)
- Prescribe FDA-approved medications for ADHD along with parent training in behavior management (PTBM) and/or behavioral classroom intervention 1, 2
- Educational interventions and individualized instructional supports are necessary components of any treatment plan and may include an Individualized Education Program (IEP) or a 504 plan 1, 5
Adolescents (12-18 years)
- Prescribe FDA-approved medications with the adolescent's assent, preferably combined with evidence-based training interventions 1, 2
- School-based training interventions have consistently shown benefits for adolescents with ADHD 5, 8
- Transition planning to adult care should begin around age 14 1, 2
Adults
- A combination of medication and CBT is recommended for adults with ADHD 1, 6
- CBT plus pharmacotherapy has shown greater benefits than pharmacotherapy alone for improving ADHD symptoms, depression, and anxiety in adults 6, 7
Important Clinical Considerations
- ADHD should be recognized as a chronic condition requiring ongoing management within a medical home model 1, 2
- Regular monitoring for medication effectiveness and side effects is essential 1, 3
- Driving ability is a crucial safety consideration in adults with ADHD, as stimulant treatment has been shown to improve driving capability 1
- For pregnant individuals with ADHD, the risks of medication exposure must be weighed against the risks of untreated ADHD, which has been associated with increased risks for spontaneous abortion and preterm birth 1
Common Pitfalls and Caveats
- Discontinuing medication without proper planning can lead to symptom recurrence and functional impairment 1, 3
- Inadequate treatment of ADHD can lead to poor long-term outcomes, including lower educational achievement, increased risk of accidents, and higher rates of comorbid psychiatric conditions 2, 5
- When treating comorbid conditions alongside ADHD, some conditions may resolve with effective ADHD treatment, while others may require additional specific interventions 1
- Atomoxetine requires daily compliance and may take several weeks to achieve full therapeutic effect, unlike stimulants which have more immediate effects 3, 4