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

Treatment of ADHD: Age-Stratified Approach

Treatment for ADHD must be tailored by age group, with stimulant medications serving as first-line pharmacotherapy for school-age children and adolescents, while preschoolers should receive behavioral interventions first. 1

Preschool-Age Children (4-5 Years)

Begin with evidence-based parent and/or teacher-administered behavior therapy as first-line treatment. 1

• Methylphenidate may be considered only if behavioral interventions fail to provide significant improvement AND there is moderate-to-severe continued functional disturbance. 1
• The decision to use medication before age 6 requires weighing the risks of early medication exposure against the harm of delaying treatment when behavioral interventions are unavailable. 1
• This age group has shown methylphenidate to be less efficacious with higher rates of adverse events compared to older children, necessitating more cautious consideration. 1

Elementary School-Age Children (6-11 Years)

Prescribe FDA-approved ADHD medications (preferably stimulants) combined with parent and/or teacher-administered behavioral interventions. 1

Medication Hierarchy by Evidence Strength:

• Stimulant medications (methylphenidate or amphetamines): Effect size ~1.0, strongest evidence (Grade A) 1
• Atomoxetine: Effect size ~0.7, sufficient evidence 1
• Extended-release guanfacine: Effect size ~0.7 1
• Extended-release clonidine: Effect size ~0.7 1

Educational Supports:

• School environment modifications, class placement adjustments, and behavioral supports are mandatory components of treatment. 1
• Formalize through an Individualized Education Program (IEP) or 504 Rehabilitation Plan. 1

Adolescents (12-18 Years)

Prescribe FDA-approved stimulant medications with the adolescent's assent as primary treatment, strongly considering addition of behavioral interventions. 1, 2

Medication Approach:

• Extended-release formulations of methylphenidate or amphetamines provide once-daily dosing with symptom coverage throughout school and evening hours, critical for adolescents who drive. 2
• Obtain adolescent assent for medication, as their preference strongly predicts treatment engagement and persistence. 2

Behavioral Interventions:

• Address functional impairments and skill deficits that medication alone does not resolve, particularly disorganization and time management. 2
• Cognitive/behavioral treatments demonstrate small-to-medium improvements for parent-rated ADHD symptoms and co-occurring emotional/behavioral symptoms. 2

Combination Treatment Benefits:

• Allows for lower stimulant dosages, potentially reducing adverse effects. 2
• Parents and teachers report significantly higher satisfaction with combined approaches. 2
• Provides complementary benefits: medication addresses core symptoms while behavioral interventions improve executive function skills. 2

Educational Supports:

• Accommodations may include extended test time, reduced homework demands, ability to keep study materials in class, and provision of teacher's notes. 2
• Transition planning to adult care should begin at approximately age 14. 2

Medication Titration and Monitoring

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

Stimulant Dosing:

• Common adverse effects include appetite loss, abdominal pain, headaches, and sleep disturbance. 1
• Growth velocity may decrease by 1-2 cm with higher, consistently administered doses, though effects diminish by the third year. 1
• Sudden cardiac death is extremely rare; expand history to include specific cardiac symptoms, Wolff-Parkinson-White syndrome, and family history of sudden death. 1

Non-Stimulant Dosing (Atomoxetine):

• Children/adolescents ≤70 kg: Start 0.5 mg/kg/day, increase after minimum 3 days to target 1.2 mg/kg/day (maximum 1.4 mg/kg or 100 mg, whichever is less). 3
• Children/adolescents >70 kg and adults: Start 40 mg/day, increase after minimum 3 days to target 80 mg/day (maximum 100 mg). 3
• Monitor for suicidal ideation, particularly early in treatment (0.4% risk vs. 0% with placebo). 3
• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating. 3

Comorbidity Management

Screen for comorbid conditions including anxiety, depression, oppositional defiant disorder, conduct disorders, learning disorders, and sleep disorders at initial evaluation. 1, 2

• If the primary care clinician is trained in diagnosing comorbidities, initiate treatment or refer to appropriate subspecialist. 1
• Reassess diagnostic formulation if response to adequate treatment is poor, considering unrecognized comorbidities, psychosocial stressors, or poor adherence. 2
• Combined medication and behavioral therapy offers greater improvements when ADHD is comorbid with anxiety. 2

Chronic Care Model

Manage ADHD as a chronic condition following principles of the chronic care model and medical home. 1

• Periodically reevaluate long-term medication usefulness for individual patients. 3
• Pharmacological treatment may be needed for extended periods. 3
• Family preference is essential in determining and maintaining the treatment plan. 1, 2

Critical Pitfalls to Avoid

• Do not prescribe medication for symptoms secondary to environmental factors or other primary psychiatric disorders including psychosis. 3
• Do not exceed maximum recommended doses: stimulants show no additional benefit at higher doses. 1
• Do not delay behavioral interventions in preschoolers—medication should only be considered after behavioral approaches fail. 1
• Do not ignore educational supports—they are a necessary component of any treatment plan regardless of age. 1, 2