What is the recommended treatment for Attention Deficit Hyperactivity Disorder (ADHD)?

ADHD Treatment

For children ages 6-18 years and adults, FDA-approved stimulant medications (methylphenidate or amphetamines) are the first-line treatment, with behavioral therapy as an essential adjunct; for preschool-aged children (4-5 years), behavioral therapy administered by parents and teachers is the first-line treatment, with methylphenidate reserved only for moderate-to-severe cases that fail behavioral interventions. 1

Treatment by Age Group

Preschool-Aged Children (4-5 years)

• Behavioral therapy is the mandatory first-line treatment, specifically parent training and behavioral classroom interventions 1
• Methylphenidate may be considered only if behavioral interventions fail to provide significant improvement AND there is moderate-to-severe continued functional disturbance 1
• Stimulants in this age group have been shown to be less efficacious and associated with higher rates of adverse events compared to school-age populations, requiring more restraint and careful consideration 1

Elementary and Middle School Children (6-11 years)

• Prescribe FDA-approved stimulant medications (methylphenidate or amphetamines) as first-line therapy 1
• Combine medication with parent training and behavioral classroom interventions (preferably both) 1
• Stimulants have the strongest evidence with an effect size of approximately 1.0 1
• Educational interventions and individualized instructional supports (including IEP when needed) are a necessary part of any treatment plan 1

Adolescents (12-18 years)

• Prescribe FDA-approved stimulant medications with the adolescent's assent 1
• Evidence-based behavioral interventions should be encouraged as adjunctive treatment 1
• School-based training interventions show consistent benefits when treatment continues over extended periods with frequent constructive feedback 2

Adults

• Stimulant medications (methylphenidate or amphetamines) are first-line treatment 3
• Approximately 60% of adults receiving stimulant medication show moderate-to-marked improvement compared with 10% receiving placebo 4
• Cognitive behavioral therapy as adjunctive treatment with medication has been shown to be helpful 3

Medication Selection Algorithm

First-Line: Stimulants

• Methylphenidate or amphetamines are the primary first-line options with the strongest evidence base 1
• Extended-release formulations are preferred for better adherence and lower risk of rebound effects 1
• If no desired benefit after adequate treatment with methylphenidate, switch to lisdexamfetamine before considering non-stimulants 1

Second-Line: Non-Stimulants

• Atomoxetine (norepinephrine reuptake inhibitor): Effect size approximately 0.7 vs. 1.0 for stimulants 1

  • Dosing for children/adolescents ≤70 kg: Start 0.5 mg/kg/day, target 1.2 mg/kg/day (max 1.4 mg/kg or 100 mg) 5
  • Dosing for children/adolescents >70 kg and adults: Start 40 mg/day, target 80 mg/day (max 100 mg) 5
  • Requires 6-12 weeks until effects are observed 1
  • Consider as first-line option in comorbid substance use disorders, disruptive behavior disorders, or tic/Tourette's disorder 1

• Extended-release guanfacine or clonidine (alpha-2 adrenergic agonists): Effect size approximately 0.7 1

  • Requires 2-4 weeks until effects are observed 1
  • Consider as first-line option in comorbid sleep disorder, substance use disorder, disruptive behavior disorders, or tic/Tourette's disorder 1
  • Somnolence/sedation is a frequent adverse effect; evening administration is preferable 1

Critical Monitoring Parameters

Stimulant Adverse Effects

• Most common: Appetite loss, abdominal pain, headaches, sleep disturbance 1
• Growth effects: Decreased growth velocity of 1-2 cm, particularly with higher and more consistently administered doses, though effects diminish by third year 1
• Cardiovascular: Monitor blood pressure and pulse at each visit 1, 6
• Rare but serious: Hallucinations and other psychotic symptoms 1

Atomoxetine Black Box Warning

• Increased risk of suicidal ideation in children and adolescents (0.4% vs. 0% with placebo) 5
• Monitor closely for suicidality, clinical worsening, or unusual changes in behavior 5
• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating 5

Follow-up Monitoring

• Record height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence at each visit 6
• Periodically reevaluate long-term usefulness of medication 5

Important Clinical Considerations

Comorbidity Management

• Identify and treat coexisting conditions (anxiety, learning disorders, mood disorders, sleep disorders, tic disorders) as they affect treatment selection 1
• For adults with coexisting depression, the combination of an antidepressant and stimulants has been shown to be safe and effective 3

Chronic Disease Management

• ADHD requires ongoing management as a chronic condition within a medical home model 2
• Pharmacological treatment may be needed for extended periods 5
• Behavioral therapy effects tend to persist over time, unlike medication effects which cease when discontinued 2

Common Pitfalls to Avoid

• Do not use stimulants in preschool-aged children without first attempting behavioral interventions 1
• Do not prescribe doses of methylphenidate higher than 1.2 mg/kg/day in children, as no additional benefit has been demonstrated 5
• Do not overlook screening for bipolar disorder before initiating atomoxetine 5
• Do not forget that educational interventions and school supports are essential components of treatment, not optional 1