How are ADHD symptoms managed?

Management of ADHD Symptoms

ADHD symptoms are most effectively managed through a combination of medication and behavioral therapy, with treatment approaches tailored according to age and symptom severity. 1

First-line Treatment by Age Group

• Preschool children (4-5 years):

  • Evidence-based behavioral parent training and classroom interventions are the first-line treatment 1
  • Methylphenidate may be considered only if behavioral interventions don't provide significant improvement and there is moderate-to-severe continued functional impairment 1

• Elementary and middle school children (6-11 years):

  • FDA-approved medications for ADHD along with behavioral therapy (parent training and classroom interventions) 1
  • Stimulant medications have the strongest evidence base, followed by atomoxetine, extended-release guanfacine, and extended-release clonidine 1

• Adolescents (12-18 years):

  • FDA-approved medications with the adolescent's assent, combined with evidence-based training interventions and behavioral therapy 1
  • Special consideration for medication coverage during driving due to increased crash risk 2, 1

Medication Management

• Stimulant medications:

  • First-line pharmacological treatment with the largest effect sizes for reducing core ADHD symptoms 1
  • Should be titrated to achieve maximum benefit with minimum adverse effects 2
  • Common side effects include decreased appetite, sleep disturbances, increased blood pressure/pulse, and headaches 1
  • Longer-acting or late-afternoon, short-acting medications may be helpful for symptom control while driving 2

• Non-stimulant medications (atomoxetine, guanfacine, clonidine):

  • Second-line options that provide "around-the-clock" effects but have smaller effect sizes compared to stimulants 1
  • Atomoxetine requires monitoring for suicidal ideation in children and adolescents 3
  • Indicated as an integral part of a total treatment program that may include psychological, educational, and social interventions 3

Behavioral Interventions

• Parent training in behavior management:

  • Teaches specific techniques to modify and shape child behavior 2
  • Involves providing rewards for desired behavior, using planned ignoring strategically, and providing appropriate consequences 2
  • Most effective when rewards and consequences are consistently applied 2

• School-based interventions:

  • Classroom adaptations such as preferred seating, modified work assignments, and test modifications 2
  • May be provided through 504 Rehabilitation Act Plans or Individualized Education Programs (IEPs) 2
  • Coordinating efforts between school and home enhances treatment effects 2

Combined Treatment Approach

• Combined medication and behavioral therapy allows for lower stimulant dosages, potentially reducing adverse effects 2
• Offers greater improvements on academic and conduct measures when ADHD is comorbid with anxiety or when the child lives in a lower socioeconomic environment 2
• Parents and teachers report higher satisfaction with combined treatment approaches 2
• Beginning treatment with behavioral intervention may produce better outcomes than beginning with medication alone 4

Special Considerations

• Comorbid conditions:

  • Treatment of ADHD may resolve some comorbid conditions like oppositional defiant disorder or anxiety 2
  • Other comorbid conditions may require additional treatment beyond ADHD management 2
  • For comorbid substance use disorders, non-stimulant medications that minimize abuse potential may be preferred 1

• Medication is not appropriate for children whose symptoms do not meet DSM criteria for ADHD, although behavioral therapy may still be beneficial 2

• Regular monitoring of height, weight, blood pressure, and pulse is necessary for children on medication 1

• Family engagement is crucial for treatment success, with parent training attendance being better when behavioral intervention is initiated before medication 4