What are the recommended assessment and treatment options for pediatric Attention Deficit Hyperactivity Disorder (ADHD)?

Assessment and Treatment for Pediatric ADHD

For pediatric ADHD, treatment should follow age-specific guidelines with behavioral therapy as first-line for preschoolers and medication plus behavioral therapy for school-aged children and adolescents. 1

Diagnostic Assessment

• Evaluation should be initiated for any child 4-18 years who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity 1
• Diagnosis requires meeting DSM criteria with documentation of impairment in more than one major setting (home, school, social), with information obtained from parents/guardians, teachers, and other clinicians involved in the child's care 1
• Assessment must include screening for coexisting conditions including emotional/behavioral disorders (anxiety, depression, oppositional defiant disorder), developmental disorders (learning disabilities), and physical conditions (tics, sleep apnea) 1
• ADHD should be recognized as a chronic condition requiring ongoing management following the principles of the chronic illness model and medical home 1

Treatment Recommendations by Age Group

Preschool-Aged Children (4-5 years)

• First-line treatment: Evidence-based parent- and/or teacher-administered behavior therapy 1
• Medication (methylphenidate) may be considered only if:
  • Behavioral interventions do not provide significant improvement
  • Child has moderate-to-severe continuing functional impairment
  • Symptoms have persisted for at least 9 months
  • Dysfunction is manifested in both home and other settings 1
• In areas where evidence-based behavioral treatments are not available, clinicians must weigh the risks of starting medication at an early age against the harm of delaying treatment 1
• Methylphenidate is the only medication with sufficient evidence for this age group, though it remains "off-label" 1
• Lower starting doses and smaller incremental increases are recommended for preschoolers 1

Elementary and Middle School-Aged Children (6-11 years)

• First-line treatment: FDA-approved medications for ADHD AND evidence-based parent/teacher-administered behavior therapy, preferably both 1
• Medication evidence strength (strongest to less strong): stimulants, atomoxetine, extended-release guanfacine, extended-release clonidine 1
• Stimulant medications (methylphenidate, amphetamine) have the strongest evidence with effect sizes of 0.8-0.9 1, 2
• For stimulant medications:
  • Methylphenidate dosing: Start at approximately 0.5 mg/kg/day and titrate to approximately 1.2 mg/kg/day 3
  • Response to methylphenidate versus amphetamine is idiosyncratic, with approximately 40% responding to both and about 40% responding to only one 1
• For non-stimulant medications:
  • Atomoxetine: Initial dose 0.5 mg/kg/day, target dose 1.2 mg/kg/day 3
  • Educational interventions and individualized instructional supports are necessary parts of any treatment plan 1

Adolescents (12-18 years)

• First-line treatment: FDA-approved medications for ADHD with the assent of the adolescent 1
• Behavioral therapy is also recommended, preferably in combination with medication 1
• Special considerations for adolescents:
  • Screen for substance use before initiating medication 1
  • Monitor for potential diversion of stimulant medications 1
  • Consider medications with less abuse potential (atomoxetine, extended-release guanfacine, extended-release clonidine, or long-acting stimulant formulations) for those at risk 1
  • Provide medication coverage for symptom control while driving 1

Behavioral Interventions

• Parent Training in Behavior Management (PTBM) is the evidence-based behavioral approach for children with ADHD 1
• Behavioral classroom interventions are also recommended, particularly for school-aged children 1
• Behavioral therapy involves training adults to influence the contingencies in an environment to improve the child's behavior 1
• Median effect size for behavioral parent training is 0.55 1
• For preschoolers, parent-child interaction therapy is an evidence-based dyadic therapy option 1

Medication Management

• Stimulant medications have the strongest evidence for efficacy in treating ADHD symptoms 1, 2
• Common side effects of stimulants include decreased appetite, weight loss, sleep problems, and potential increases in heart rate and blood pressure 4
• Non-stimulant options include:
  • Atomoxetine: Selective norepinephrine reuptake inhibitor 1, 3
  • Extended-release guanfacine and clonidine: Selective α-2 adrenergic agonists 1
  • Newer options like viloxazine extended-release are also available for children and adults 5
• Medication doses should be titrated to achieve maximum benefit with minimum adverse effects 1
• Periodic reevaluation of medication effectiveness and continued need is essential 3

Special Considerations

• For children with intellectual disability (ID) and ADHD, methylphenidate has shown efficacy with an effect size of 0.39-0.52 1
• Risperidone has shown efficacy for irritability and aggression in children with ID and may have benefits for hyperactivity when added to stimulants 1
• Transition planning to adult care should begin around age 14 and focus specifically during the 2 years preceding high school completion 1
• ADHD treatment should be viewed as long-term, as longitudinal studies show increased risk of significant problems if treatment is discontinued 1

Treatment Monitoring

• Regular communication between clinicians, parents, teachers, and patients is essential 1
• Periodic reevaluation of the long-term usefulness of medication for the individual patient is necessary 3
• Monitor for side effects, particularly growth, weight, blood pressure, and heart rate with stimulants 4
• Assess ongoing need for medication and behavioral interventions as part of a chronic care approach 1