How to manage hyperactivity in children?

Managing Hyperactivity in Children

For children with hyperactivity, the treatment approach depends critically on age: behavioral parent training is first-line for preschoolers (ages 4-5), while FDA-approved stimulant medications combined with behavioral interventions are first-line for school-age children (ages 6-11), and stimulant medications with the child's assent are first-line for adolescents (ages 12-18). 1

Initial Assessment Requirements

Before initiating treatment, confirm the child meets DSM-5 criteria for ADHD with symptoms of inattention, hyperactivity, or impulsivity causing functional impairment in at least two settings (home, school, social environments). 1, 2

• Obtain standardized rating scales from both parents and teachers to document symptoms across multiple settings 3, 2
• Screen for comorbid conditions including anxiety, depression, oppositional defiant disorder, learning disabilities, and sleep disorders, as these frequently coexist and require separate treatment 1, 2
• Rule out bipolar disorder, mania, or hypomania before starting any medication 4

Age-Specific Treatment Algorithms

Preschool Children (Ages 4-5 Years)

Start with behavioral parent training as the sole intervention. 1

• Implement parent training in behavior management (PTBM) teaching specific techniques: positive reinforcement for desired behaviors, planned ignoring for non-adaptive behaviors, and appropriate consequences when goals are not met 1, 5
• Train parents to consistently apply rewards immediately when tasks are achieved, then gradually increase expectations as behaviors are mastered 1
• Continue behavioral interventions for at least 8 weeks before considering medication 5

Add methylphenidate only if: 1

• Behavioral interventions provide insufficient improvement after adequate trial
• Moderate-to-severe functional impairment persists
• The benefits of early medication outweigh the risks in your clinical judgment

School-Age Children (Ages 6-11 Years)

Prescribe FDA-approved stimulant medications (methylphenidate or amphetamine preparations) as first-line pharmacotherapy, combined with behavioral parent training and classroom behavioral interventions. 1, 2

Medication Initiation Protocol:

For children ≤70 kg: 4

• Start methylphenidate or amphetamine at low doses
• Titrate weekly to achieve maximum benefit with minimum adverse effects 1, 2
• Target the dose that optimally controls symptoms, not a fixed mg/kg calculation 2

For children >70 kg: 4

• 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 is suboptimal

Why Stimulants Are Preferred:

• Stimulant medications have effect sizes around 1.0 for reducing core ADHD symptoms, significantly stronger than behavioral therapy alone 1, 3, 2
• Non-stimulants (atomoxetine, extended-release guanfacine, extended-release clonidine) have effect sizes around 0.7, making them second-line options 1
• More than 70% of children respond optimally to one of the stimulant medications when systematically titrated 2

Concurrent Behavioral Interventions:

Implement both home and school behavioral programs: 1, 2

• Parent training teaches effective behavior modification techniques at home 1, 6
• Classroom behavioral interventions include preferred seating, modified assignments, test accommodations, and behavioral plans 1, 2
• Formalize school supports through an Individualized Education Program (IEP) or 504 Rehabilitation Plan 1, 2

Why Combined Treatment Matters:

• Combined medication and behavioral therapy allows lower stimulant doses while maintaining efficacy, potentially reducing adverse effects 1, 3
• Parents report significantly higher satisfaction with combined treatment compared to medication alone 1
• Combined treatment shows small but significant additional improvements (effect size d=0.26-0.28) beyond medication alone on parent-teacher symptom ratings 1, 3
• Behavioral therapy effects persist with continued adherence, while medication effects cease when stopped 1

Adolescents (Ages 12-18 Years)

Prescribe FDA-approved stimulant medications with the adolescent's assent, preferably combined with training interventions targeting organizational skills and time management. 1, 2

• Stimulant medications remain highly effective for reducing core ADHD symptoms in adolescents 1
• Training interventions focused on school functioning skills (organization, time management) consistently show benefits for this age group 1
• Ensure medication coverage during driving hours, as adolescents with ADHD have increased crash and violation risks 1, 3
• Modified behavioral family approaches that include both parents and adolescents together to develop behavioral contracts have mixed evidence and are less effective than parent training for younger children 1

Monitoring Schedule

During initial titration (first 3-6 months): 3, 2

• Assess weekly during dose adjustment using standardized parent and teacher rating scales
• Monitor for common stimulant adverse effects: appetite loss, abdominal pain, headaches, sleep disturbance, and growth velocity reduction (1-2 cm over time) 3, 2

After stabilization: 2

• Reassess every 3-6 months using standardized ratings from multiple observers
• Monitor growth parameters at each visit 7
• Periodically reevaluate long-term medication necessity 4

Common Pitfalls to Avoid

Don't rely solely on parent reports for medication effects—teachers may report different side effects, and medication benefits may be setting-specific. 3

Don't assume medication alone addresses all impairments—academic achievement, peer relationships, and family functioning often require behavioral interventions even when core symptoms improve. 1, 3

Don't expect immediate behavioral therapy results—unlike medication's rapid onset, behavioral interventions require consistent implementation over 8+ weeks to show benefits. 3, 5

Don't use medication for children whose symptoms don't meet DSM-5 criteria for ADHD—behavioral interventions may still be appropriate for subthreshold symptoms. 1

Treatments NOT Recommended

The following lack sufficient evidence or have been found ineffective for ADHD: 1

• Mindfulness training
• Cognitive training
• Diet modification
• EEG biofeedback
• Supportive counseling alone
• Social skills training
• Cannabidiol oil (anecdotal evidence only)
• External trigeminal nerve stimulation (insufficient long-term data)