What are the diagnostic and treatment options for Attention Deficit Disorder (ADD)?

Diagnosing and Treating Attention Deficit Disorder (ADD/ADHD)

Diagnosis

ADHD diagnosis requires documentation of DSM-5 criteria with symptoms and functional impairment present in at least two major settings (home, school, work), obtained from multiple informants including parents, teachers, and the patient themselves. 1, 2

Core Diagnostic Criteria

• Inattentive presentation: At least 6 symptoms persisting ≥6 months including lack of attention to details, difficulty sustaining attention, poor listening, failure to follow through on tasks, poor organization, avoidance of sustained mental effort, losing things, easy distractibility, and forgetfulness 3
• Hyperactive-impulsive presentation: At least 6 symptoms persisting ≥6 months including fidgeting/squirming, leaving seat inappropriately, excessive running/climbing, difficulty with quiet activities, being "on the go," excessive talking, blurting answers, inability to wait turn, and intrusiveness 3
• Combined presentation: Both inattentive and hyperactive-impulsive criteria must be met 3

Essential Pre-Treatment Screening

• Screen for comorbid conditions that significantly impact treatment planning: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use disorders, learning disorders, language disorders, autism spectrum disorders, tics, sleep apnea, and restless leg syndrome 1, 2
• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating any ADHD medication 3
• Obtain personal and family cardiac history before starting medication, with baseline ECG if risk factors are present, particularly before non-stimulants 2

Treatment Algorithm by Age

Preschool Children (Ages 4-5 Years)

Start with evidence-based parent-administered behavioral therapy as first-line treatment; only consider methylphenidate if behavioral interventions fail to provide significant improvement AND there is moderate-to-severe continuing functional disturbance. 1, 2

• Parent training in behavioral management techniques (positive reinforcement, planned ignoring, appropriate consequences) is Grade A evidence 1, 2
• Methylphenidate dosing if needed: Start at 0.5 mg/kg/day, titrate to target of 1.2 mg/kg/day (Grade B evidence) 1

School-Age Children (Ages 6-11 Years)

Prescribe FDA-approved stimulant medications as first-line treatment, preferably combined with both parent training and behavioral classroom interventions. 1, 2

Medication Hierarchy by Evidence Strength:

1. Stimulants (methylphenidate or amphetamines): Strongest evidence with effect sizes ~1.0, Grade A 1, 2, 4
2. Atomoxetine: Effect size ~0.7, Grade A but weaker than stimulants 1, 2
3. Extended-release guanfacine: Effect size ~0.7, lesser evidence than atomoxetine 1, 2
4. Extended-release clonidine: Most limited evidence, effect size ~0.7 1, 2

Stimulant Dosing Protocol:

• Children ≤70 kg: Start at 0.5 mg/kg/day, increase after minimum 3 days to target of 1.2 mg/kg/day, maximum 1.4 mg/kg or 100 mg (whichever is less) 3
• Children >70 kg: Start at 40 mg/day, increase after minimum 3 days to target of 80 mg/day, may increase to maximum 100 mg after 2-4 additional weeks if suboptimal response 3
• Extended-release formulations provide once-daily dosing with symptom coverage throughout the school day 5, 2

Non-Negotiable Behavioral Components:

• Parent training in behavioral management (Grade A evidence) 1, 2
• Behavioral classroom interventions including daily report cards, point systems, and academic skill remediation (Grade A evidence) 1
• Educational supports: IEP or 504 plan are necessary components, not optional 1, 2

Adolescents (Ages 12-17 Years)

Prescribe FDA-approved stimulant medications with the adolescent's assent as primary treatment (Grade A), and strongly consider adding evidence-based behavioral interventions to address functional impairments that medication alone does not fully resolve. 1, 5, 2

Key Implementation Points:

• Obtain adolescent's assent for medication treatment, as their preference strongly predicts treatment engagement and persistence 1, 5, 2
• Extended-release formulations are particularly important for adolescents who need symptom control while driving, given the elevated crash risk in untreated ADHD 1, 5
• Monitor for medication misuse or diversion through prescription drug monitoring programs; consider non-stimulants (atomoxetine, extended-release guanfacine/clonidine) if diversion risk is high 1

Behavioral Interventions for Adolescents:

• Cognitive-behavioral therapy demonstrates small to medium improvements for parent-rated ADHD symptoms and co-occurring emotional/behavioral symptoms 5
• Training interventions target skill development through repeated practice with performance feedback, particularly effective for disorganization and time management 5

Adults

Stimulant medications remain first-line treatment with similar response rates to children at equivalent mg/kg doses, with long-acting formulations (OROS methylphenidate, dexmethylphenidate, mixed amphetamine salts XR) providing 10-12 hours of coverage. 6

• For adults who don't respond to stimulants or have contraindications, atomoxetine is an appropriate alternative 6
• Cognitive-behavioral therapy in addition to pharmacotherapy improves treatment response 7, 6
• For coexisting depression, combination of antidepressant and stimulants is safe and effective 7

Combination Treatment Approach

Combining medication with behavioral therapy provides complementary benefits: medication addresses core ADHD symptoms while behavioral interventions improve functional impairments, executive function skills, and coping strategies. 5

Evidence from the MTA Study:

• Combined treatment (medication + behavioral therapy) was not significantly more effective than medication alone for core ADHD symptoms in primary analysis 1
• However, secondary analysis showed significant advantage for combination with effect size d=0.28 1
• Combined treatment offered greater improvements on academic and conduct measures when ADHD was comorbid with anxiety or the child lived in lower socioeconomic environment 1
• Parents and teachers reported significantly higher satisfaction with combined treatment 1
• Combination allowed lower stimulant dosages, potentially reducing adverse effects 1

Medication Titration and Monitoring

Titrate medication doses to achieve maximum benefit with tolerable side effects, starting at the lowest dose with weekly follow-up during titration phase. 1, 2

Specific Titration Protocols:

• Stimulants: Start low, increase every 3-7 days based on response and tolerability; more than 70% of children respond to methylphenidate when full dose range is systematically trialed 1
• Atomoxetine: Increase gradually to minimize initial somnolence and GI symptoms; monitor for suicidal ideation (FDA black box warning) 2, 3
• Alpha-2 agonists (guanfacine/clonidine): Taper gradually rather than abrupt discontinuation to avoid rebound hypertension 2

Ongoing Monitoring:

• Height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence at each follow-up 4, 6
• Monitor for decreased appetite, sleep disturbances, cardiovascular effects with stimulants 2
• Watch for rare hepatitis with atomoxetine 2
• Monitor for somnolence, dry mouth, dizziness, irritability, headache, bradycardia, hypotension with alpha-2 agonists 2

Special Dosing Adjustments

Hepatic Impairment:

• Moderate hepatic impairment (Child-Pugh Class B): Reduce atomoxetine dose to 50% of normal 3
• Severe hepatic impairment (Child-Pugh Class C): Reduce atomoxetine dose to 25% of normal 3

CYP2D6 Poor Metabolizers or Strong Inhibitors:

• Children ≤70 kg: Start atomoxetine at 0.5 mg/kg/day, increase to 1.2 mg/kg/day only if symptoms fail to improve after 4 weeks and initial dose is well tolerated 3
• Children >70 kg and adults: Start atomoxetine at 40 mg/day, increase to 80 mg/day only if symptoms fail to improve after 4 weeks and initial dose is well tolerated 3

Critical Pitfalls to Avoid

• Do not prescribe medication for children whose symptoms don't meet DSM-5 criteria for ADHD 1
• Do not use medication alone without educational supports and accommodations 1, 2
• Do not fail to screen for comorbidities before treatment initiation, as they significantly impact treatment planning and outcomes 1, 2
• Do not continue ineffective treatment without reassessing the diagnostic formulation for unrecognized comorbidities, psychosocial stressors, or poor adherence 5
• Do not abruptly discontinue alpha-2 agonists due to rebound hypertension risk 2
• Do not open atomoxetine capsules; they must be taken whole 3

Chronic Disease Management

Recognize ADHD as a chronic condition requiring ongoing care following the chronic care model, with periodic reevaluation of long-term medication usefulness. 2, 3

• Establish collaborative communication systems with schools and mental health professionals 2
• Begin transition planning to adult care at approximately age 14, with specific focus during the 2 years preceding high school completion 5
• Pharmacological treatment may be needed for extended periods; maintenance treatment has demonstrated benefit in controlled trials 3