What are the types of Attention Deficit Hyperactivity Disorder (ADHD) and their management?

ADHD Types and Management

ADHD presents in three distinct types—predominantly inattentive, predominantly hyperactive-impulsive, and combined presentation—with treatment requiring behavioral interventions as first-line for children and stimulant medications (methylphenidate or amphetamines) as the most effective pharmacotherapy when symptoms cause significant impairment. 1

ADHD Subtypes

The three presentations of ADHD are defined by specific symptom clusters that must persist for at least 6 months: 1, 2

• Predominantly Inattentive Type: Requires at least 6 symptoms including lack of attention to details/careless mistakes, lack of sustained attention, poor listening, failure to follow through on tasks, poor organization, avoidance of tasks requiring sustained mental effort, losing things, easy distractibility, and forgetfulness 2

• Predominantly Hyperactive-Impulsive Type: Requires at least 6 symptoms including fidgeting/squirming, leaving seat inappropriately, inappropriate running/climbing, difficulty with quiet activities, being "on the go," excessive talking, blurting answers, inability to wait turn, and intrusiveness 2

• Combined Type: Must meet criteria for both inattentive and hyperactive-impulsive presentations 2

Adults with ADHD are more likely to present with predominantly inattentive symptoms, with hyperactivity often becoming internalized rather than externalized. 1, 3

Management Algorithm by Age Group

Preschool-Aged Children (4-5 years)

Prescribe evidence-based parent- and/or teacher-administered behavior therapy as first-line treatment. 1 Methylphenidate may be prescribed only if behavioral interventions fail to provide significant improvement and moderate-to-severe functional disturbance persists. 1 The risks of early medication initiation must be weighed against the harm of delaying treatment in areas where evidence-based behavioral treatments are unavailable. 1

School-Aged Children and Adolescents (6-18 years)

The treatment approach follows a structured sequence: 1, 4

First-Line: Psychosocial Interventions

• School environment management and behavioral interventions should be implemented before medication 4
• Parental training in behavior management is essential 4
• Behavioral classroom interventions must be established 4
• Consider social skills training, cognitive behavioral therapy, and biofeedback 4

Second-Line: Pharmacological Treatment Add medication when symptoms cause persistent significant impairment in at least one domain despite psychosocial interventions: 4

• Stimulants (First-Line Pharmacotherapy): 4, 5

  • Methylphenidate formulations (short-acting, intermediate-acting, long-acting): Start at 0.5 mg/kg/day for children ≤70 kg, increase after minimum 3 days to target of 1.2 mg/kg/day (maximum 1.4 mg/kg or 100 mg, whichever is less) 2
  • Amphetamine formulations: Available in short-acting and long-acting options 4, 6
  • For children >70 kg: Start at 40 mg daily, increase after 3 days to target of 80 mg, may increase to maximum 100 mg after 2-4 additional weeks if needed 2

• Non-Stimulants (When stimulants ineffective, not tolerated, or contraindicated): 5, 2

  • Atomoxetine: Robust evidence of efficacy; monitor for suicidal ideation (0.4% risk vs 0% placebo in pediatric trials) 2
  • Extended-release guanfacine 5
  • Extended-release clonidine 5

Combination Treatment: Behavioral therapy combined with medication offers advantages including lower required stimulant dosages (reducing adverse effects), greater parent/teacher satisfaction, and improved outcomes for ADHD with comorbid anxiety or lower socioeconomic environments. 1

Adults

First-Line Pharmacotherapy: 5, 3

• Methylphenidate formulations (short-acting, intermediate-acting, long-acting): Start at 40 mg daily, increase to target 80 mg, maximum 100 mg 5, 2
• Amphetamine stimulants: Clinical guidelines recommend specific amphetamine and methylphenidate formulations as first-line 3

Alternative Options: 5, 3

• Atomoxetine: For patients unable to take stimulants or with concurrent anxiety/depression 5, 3
• Viloxazine: For patients unable to take stimulants 3
• Bupropion: For concurrent anxiety/depression 3
• Extended-release guanfacine and clonidine: When stimulants contraindicated 5

Non-Pharmacological Interventions (implement concurrently with medication): 5

• Psychoeducation about ADHD 5
• Recovery-focused care considering individual values, goals, and strengths 5
• Cognitive-behavioral therapy (most studied and effective non-pharmacologic option) 1
• Mindfulness-based interventions and dialectical behavior therapy 1

Critical Management Principles

ADHD is a chronic condition requiring long-term management following chronic care model and medical home principles. 1 This approach is particularly beneficial for parents who also have ADHD themselves. 1

Mandatory Comorbidity Screening: 1

• Screen for emotional/behavioral conditions (anxiety, depression, oppositional defiant disorder, conduct disorders, substance use) 1
• Assess developmental conditions (learning disabilities, language disorders, autism spectrum disorders) 1
• Evaluate physical conditions (tics, sleep apnea) 1
• For adolescents: Minimum assessment must include substance use, anxiety, depression, and learning disabilities 1

Medication Monitoring: 4, 5

• Start at lower doses and monitor for side effects and improvement after each increment 4
• Periodically reevaluate long-term medication usefulness 4
• Regular monitoring of treatment efficacy, side effects, and functional outcomes 5
• For adults on stimulants: Consider controlled substance agreements and prescription drug monitoring programs to prevent misuse/diversion 3

Common Pitfalls and Caveats

Medication is not appropriate for children whose symptoms do not meet DSM-5 criteria for ADHD, though psychosocial treatments may still benefit these children. 1

Treatment discontinuation is common: More than 33% of children and 50% of adults discontinue treatment during the first year, often due to lack of individual drug response and tolerability issues. 7 This places patients at higher risk for motor vehicle crashes, criminality, depression, and other injuries. 1

School-based services fall into two categories: interventions to help students independently meet expectations (daily report cards, point systems, academic remediation) versus accommodations that modify the program (extended test time, reduced homework, provision of teacher notes). 1 These serve different purposes and should not be confused.

Perinatal considerations: For pregnant/postpartum individuals with moderate-to-severe ADHD, the risks of perinatal ADHD medication must be balanced against risks of inadequately treated ADHD, with largely reassuring safety data for ADHD medications in pregnancy. 1 Methylphenidate and bupropion can be maintained at therapeutic doses during breastfeeding, while amphetamine derivatives require discussion of breastfeeding safety. 1