What is the initial treatment for a 13-year-old with inattentive Attention Deficit Hyperactivity Disorder (ADHD)?

Initial Treatment for Inattentive ADHD in a 13-Year-Old

For a 13-year-old with inattentive ADHD, initiate treatment with FDA-approved stimulant medication (methylphenidate or amphetamine), with or without behavioral therapy, after screening for substance use and assessing for diversion risk. 1

Pre-Treatment Assessment

Before initiating medication in this adolescent, you must:

• Screen for substance use symptoms - if active substance use is identified, refer to a subspecialist before treating ADHD 1
• Assess for diversion risk - medication misuse and sharing with peers is a particular concern in adolescents 1
• Screen for bipolar disorder - evaluate personal or family history of bipolar disorder, mania, or hypomania before starting treatment 2

First-Line Pharmacologic Treatment

Stimulant medications are the first-line treatment with the strongest evidence for efficacy in adolescents aged 12-18 years 1:

• Methylphenidate is the most commonly used stimulant with significant evidence for reducing ADHD symptoms and improving social skills 3, 4
• Amphetamines are also FDA-approved with strong evidence 1
• The evidence is particularly strong for stimulants, with sufficient but less strong evidence for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order) 1

Dosing Strategy for Adolescents

For adolescents over 70 kg (which many 13-year-olds are):

• Start atomoxetine at 40 mg daily if choosing a non-stimulant
• Increase after minimum 3 days to target dose of 80 mg daily
• May increase to maximum 100 mg after 2-4 additional weeks if response inadequate 2

Longer-acting formulations are preferred for adolescents to:

• Minimize diversion potential 1
• Provide symptom control during driving (critical safety concern) 1
• Improve adherence by eliminating need for school-day dosing 5

Considerations for Minimizing Diversion Risk

If diversion is a significant concern, consider prescribing:

• Non-stimulant medications: atomoxetine, extended-release guanfacine, or extended-release clonidine (no abuse potential) 1
• Stimulants with lower abuse potential: lisdexamfetamine (requires metabolic activation), dermal methylphenidate, or OROS methylphenidate (difficult to extract) 1

Role of Behavioral Therapy

Behavioral therapy may be prescribed as an adjunct to medication in adolescents, though the evidence is weaker (Grade C recommendation) compared to younger children 1:

• Combination treatment allows for lower stimulant dosages, potentially reducing adverse effects 1
• Combined therapy showed greater parent and teacher satisfaction 1
• Behavioral interventions do not require a specific ADHD diagnosis to be beneficial 1

Monitoring Requirements

Monitor prescription refill requests and symptoms for signs of:

• Medication misuse or diversion to parents, classmates, or acquaintances 1
• Utilize prescription drug monitoring programs (required in most states) 1

Titrate medication doses to achieve maximum benefit with minimum adverse effects 1:

• Common non-serious adverse events include decreased appetite, sleep problems, and growth effects 6, 4
• Most adverse events are mild and transient 6
• Serious adverse events appear rare with stimulants 4

Common Pitfalls to Avoid

• Inadequate dosing is a common reason for treatment failure - ensure proper dose optimization before declaring inadequate response 7
• Poor adherence (20-65% noncompliance rates) often stems from adverse effects, lack of effectiveness concerns, or inconvenience - address these barriers directly 5
• Assuming medication alone is sufficient - while medication has the strongest evidence for core ADHD symptoms, school accommodations and family-school partnerships enhance outcomes 1