What are the guidelines for prescribing Attention Deficit Hyperactivity Disorder (ADHD) medications?

Guidelines for Prescribing ADHD Medications

Prescribe FDA-approved stimulant medications as first-line pharmacotherapy for ADHD, with treatment approach stratified by age: behavioral therapy first for preschoolers (ages 4-5), stimulants with or without behavioral therapy for school-age children (ages 6-11), and FDA-approved medications with patient assent for adolescents and adults (ages 12+). 1

Age-Specific Treatment Algorithms

Preschool-Age Children (4-5 Years)

• Start with evidence-based parent and/or teacher-administered behavioral therapy as first-line treatment 1
• Consider methylphenidate only if behavioral interventions fail to provide significant improvement AND there is moderate-to-severe continuing functional disturbance 1
• Weigh the risks of starting medication before age 6 against the harm of delaying treatment when behavioral therapy is unavailable 1
• Note that methylphenidate use in this age group remains off-label despite being the best-studied medication in preschoolers 1

Elementary and Middle School Children (6-11 Years)

• Prescribe FDA-approved stimulant medications as first-line treatment, preferably combined with parent and/or teacher-administered behavioral therapy 1
• Evidence strength hierarchy: stimulant medications (strongest) > atomoxetine > extended-release guanfacine > extended-release clonidine 1
• Methylphenidate is the preferred first-choice medication in children and adolescents based on efficacy and safety profiles 2
• School environment and behavioral classroom interventions are necessary components of any treatment plan 1

Adolescents (12-17 Years)

• Prescribe FDA-approved medications with the adolescent's assent as primary treatment 1
• Behavioral therapy may be added but has weaker evidence (Grade C) in this age group 1
• Stimulant medications remain first-line with strong evidence (Grade A) 1

Adults (18+ Years)

• Amphetamines are the preferred first-choice medication in adults based on superior efficacy 2
• Methylphenidate, atomoxetine, and bupropion are also effective alternatives with moderate effect sizes 2
• Obtain adolescent's assent when treating patients ages 12-18 1
• In France and some countries, methylphenidate prescription in adults is off-label and requires specialized consultation frameworks 3, 4

Medication Selection and Dosing

Stimulant Medications (First-Line)

• Stimulants have the strongest evidence with effect sizes of approximately 1.0 1
• Methylphenidate and amphetamines are superior to placebo in reducing core ADHD symptoms (SMD -0.78 to -1.02 in children; -0.49 to -0.79 in adults) 2
• Start at the lowest dose and titrate to achieve maximum benefit with tolerable side effects 1
• Amphetamines show superior efficacy compared to methylphenidate, atomoxetine, and modafinil in head-to-head comparisons 2

Non-Stimulant Medications (Second-Line)

• Atomoxetine has an effect size of approximately 0.7, weaker than stimulants but FDA-approved 1
• Extended-release guanfacine and extended-release clonidine also have effect sizes of approximately 0.7 1
• Consider non-stimulants when stimulants are contraindicated, not tolerated, or partially effective 1
• Only extended-release guanfacine and extended-release clonidine have FDA approval for adjunctive use with stimulants 1

Pre-Treatment Evaluation Requirements

Diagnostic Confirmation

• Confirm DSM-5 criteria are met with documentation of symptoms and impairment in more than one major setting 1
• Obtain information from multiple sources: parents/guardians, teachers, school personnel, and mental health clinicians 1
• Rule out alternative causes for symptoms 1

Comorbidity Screening

• Screen for emotional/behavioral conditions (anxiety, depression, oppositional defiant disorder, conduct disorders, substance use) 1
• Screen for developmental conditions (learning disorders, language disorders, autism spectrum disorders) 1
• Screen for physical conditions (tics, sleep apnea, restless leg syndrome) 1
• Comorbidities occur in 80% of adults with ADHD and significantly complicate diagnosis and treatment 4

Cardiovascular Assessment

• Obtain personal and family cardiac history before initiating any ADHD medication 1
• Perform baseline electrocardiogram if risk factors are present, particularly before starting non-stimulants 1
• Monitor for cardiovascular parameter changes: stimulants may increase heart rate and blood pressure; guanfacine and clonidine may decrease them 1

Baseline Measurements

• Document height, weight, heart rate, and blood pressure before treatment initiation 5
• Obtain biological check-up and electrocardiogram systematically before methylphenidate in adults 3

Titration and Monitoring Protocol

Dose Titration

• Start at the lowest dosage and titrate to achieve maximum benefit with minimum adverse effects 1
• Conduct weekly follow-up during titration phase to assess efficacy and safety 3
• For atomoxetine, increase dosage gradually to minimize initial somnolence and gastrointestinal symptoms 1

Ongoing Monitoring

• Record height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence at all follow-up visits 5
• Reassess every 3 months after treatment stabilization 3
• Monitor for growth delays with atomoxetine (typically return to expected measurements after 2-3 years) 1
• Watch for suicidal ideation with atomoxetine (FDA black box warning) 1

Critical Safety Considerations

Stimulant-Specific Warnings

• Amphetamines have inferior tolerability compared to placebo (OR 2.30 in children; 3.26 in adults for dropout due to side effects) 2
• Monitor for decreased appetite, sleep disturbances, and cardiovascular effects 1
• Stimulants are classified as controlled substances requiring secured prescriptions 3

Non-Stimulant-Specific Warnings

• Taper guanfacine and clonidine gradually rather than abrupt discontinuation to avoid rebound hypertension 1
• Monitor for somnolence, dry mouth, dizziness, irritability, headache, bradycardia, and hypotension with alpha-2 agonists 1
• Watch for rare hepatitis with atomoxetine 1

Special Population Considerations

• Methylphenidate is the only medication with adequate evidence in preschool-age children, though use remains off-label 1
• No nonstimulant has sufficient evidence for use in children ages 4-5 years 1
• In adults, methylphenidate prescription may require multidisciplinary consultation frameworks in some countries due to off-label status 3, 4

Chronic Disease Management Approach

• Recognize ADHD as a chronic condition requiring medical home principles and chronic care model management 1
• Establish collaborative communication systems with schools and mental health professionals 1
• Educational interventions including IEP or 504 plans are necessary components of treatment 1
• Consider multimodal management including psychoeducation, cognitive-behavioral therapy, and family therapy as adjuncts to medication 6, 4