What are the treatment options for Attention Deficit Hyperactivity Disorder (ADHD), as indicated by the code F90?

Treatment Options for ADHD (F90)

Treatment Approach: Psychosocial First, Then Medication

The recommended treatment strategy begins with school environment management and psychosocial interventions as first-line therapy, adding pharmacological treatment as second-line when symptoms cause persistent significant impairment despite environmental modifications. 1

First-Line: Psychosocial Interventions

• Parental training in behavior management and behavioral classroom interventions are essential initial components before considering medication 1
• Social skills training, cognitive behavioral therapy, and biofeedback should be incorporated into the comprehensive treatment approach 1
• These interventions are particularly emphasized in recent Asian guidelines (2022 Japanese guidelines), though Western guidelines typically integrate behavioral interventions alongside medication 2, 1

Second-Line: Pharmacological Treatment

Medication should be added when psychosocial interventions alone are insufficient and symptoms cause persistent significant impairment in at least one domain 1

Pharmacological Treatment Algorithm

First-Line Medications: Stimulants

Long-acting stimulant formulations are strongly preferred as first-line pharmacological treatment, with efficacy in 70-80% of patients. 3

Methylphenidate Formulations

• Methylphenidate demonstrates 78% response rates versus 4% placebo when dosed appropriately at approximately 1 mg/kg total daily dose 3
• Long-acting formulations (such as Concerta) are preferred over short-acting preparations due to better medication adherence, lower risk of rebound effects, more consistent symptom control throughout the day, and reduced diversion potential 3
• For adults, methylphenidate should be administered in divided doses 2-3 times daily if using short-acting formulations, with maximum recommended daily dose of 60 mg and average effective dose of 20-30 mg daily 3
• FDA-approved for ADHD treatment as an integral part of a total treatment program 4

Amphetamine Formulations

• Amphetamine-based stimulants are preferred for adults based on comparative efficacy studies 3
• FDA-approved for ADHD in pediatric patients ages 3-16 years as part of a total treatment program 4
• Response to methylphenidate versus amphetamine is idiosyncratic: approximately 40% respond to both, 40% respond to only one 3
• If response to one stimulant class is inadequate, trial the other class before moving to non-stimulants 3

Stimulant Monitoring and Precautions

• Regular vital sign monitoring (blood pressure, pulse) is necessary with stimulant use 3
• Exercise particular caution when prescribing stimulants to adults with comorbid substance abuse disorder 3
• Screen for substance abuse disorder before prescribing, as this is of particular concern in adults 3
• Common adverse effects include loss of appetite, insomnia, anxiety, headache, and weight loss 3, 5
• Stimulants have high potential for abuse and dependence and should be handled safely to prevent misuse 5

Second-Line Medications: Non-Stimulants

Non-stimulants should be considered when: (1) active substance abuse disorder exists, (2) inadequate response or intolerable side effects to stimulants occur, (3) comorbid tics or severe anxiety are present, or (4) patient/family preference 3

Atomoxetine (Selective Norepinephrine Reuptake Inhibitor)

• FDA-approved for ADHD treatment in pediatric and adult patients as an integral part of a total treatment program 6
• Atomoxetine requires 6-12 weeks to achieve full therapeutic effect, with median time to response of 3.7 weeks, and probability of improvement may continue increasing up to 52 weeks 3
• Demonstrates medium-range effect sizes of approximately 0.7 compared to stimulants (effect size 1.0) 3
• Particularly useful for night shift workers with ADHD due to 24-hour coverage without disrupting sleep-wake cycles 3
• Initial dosing in children/adolescents up to 70 kg: approximately 0.5 mg/kg/day initially 6
• BLACK BOX WARNING: Increased risk of suicidal ideation in children and adolescents (0.4% vs 0% placebo); requires close monitoring for suicidality, clinical worsening, or unusual behavioral changes 6

Alpha-2 Adrenergic Agonists (Guanfacine ER, Clonidine ER)

• Extended-release guanfacine or clonidine demonstrate effect sizes around 0.7 and can be used as monotherapy or adjunctive therapy with stimulants if monotherapy is insufficient 3
• Dosing consideration for guanfacine: 0.1 mg/kg as a rule of thumb 3
• Should be administered in the evening due to relatively frequent somnolence/fatigue as adverse effects 3
• Can be administered before daytime sleep to leverage sedative effects in night shift workers with ADHD 3
• Allow 2-4 weeks for treatment effects when trialing these agents 3

Bupropion

• Bupropion has shown anecdotal benefits in adults with ADHD and may be particularly useful when depression is comorbid 3
• Additional non-stimulant option for adult ADHD treatment 3

Viloxazine

• Additional non-stimulant option, though it has limited data on efficacy for adult ADHD treatment 3

Treatment Algorithm for Medication Selection

1. Start with long-acting stimulant (methylphenidate or amphetamine) 3
2. If inadequate response to first stimulant class, trial the other stimulant class 3
3. If both stimulant classes fail or are contraindicated, trial atomoxetine 3
4. If atomoxetine is insufficient or not tolerated, trial extended-release guanfacine or clonidine 3
5. Consider combination therapy (stimulant + alpha-2 agonist) for comorbid conditions or insufficient monotherapy response 3

Special Considerations and Monitoring

Comorbid Anxiety

• The presence of anxiety does not contraindicate stimulant use but requires careful monitoring 3
• Stimulants can directly improve executive function deficits by enhancing dopamine and norepinephrine in prefrontal cortex networks, which can indirectly reduce anxiety related to functional impairment 3
• Anxiety symptom tracking is essential to ensure comorbid anxiety is not worsening 3

Comorbid Substance Abuse

• Prescribing psychostimulants to adults with comorbid substance abuse is of particular concern and requires careful screening 3
• Long-acting formulations like Concerta are resistant to tampering, making them more suitable for adolescents and those at risk for substance misuse 3

Collateral Information

• Adults with ADHD are unreliable reporters of their own behaviors; obtain collateral information from family members or close contacts when possible 3

Medication Titration

• Medications should be started at lower doses and monitored for side effects and improvement after each increment, with periodic reevaluation of long-term usefulness 1
• Effectiveness evaluation should be based on reduction in core ADHD symptoms and improvement in functional domains 3

Common Pitfalls to Avoid

• Do not abandon stimulants prematurely: 75-90% of patients respond well if two different stimulants (amphetamine and methylphenidate) are tried 7
• Do not expect immediate results from atomoxetine: Full therapeutic effect requires 6-12 weeks, unlike stimulants which work within hours 3
• Do not overlook stimulant optimization: Ensure adequate dosing and trial of both stimulant classes before declaring stimulant failure 8
• Do not ignore wearing-off effects: Consider time-action properties of stimulants and adjust formulations or dosing schedules accordingly 8
• Do not prescribe medication alone: ADHD treatment requires a comprehensive program including psychological, educational, and social measures 6