What is the recommended diagnostic work‑up and management plan for attention‑deficit/hyperactivity disorder, including medication selection, dosing, monitoring, and non‑pharmacologic interventions?

Management of ADHD

For children aged 6-11 years and adolescents aged 12-18 years, FDA-approved stimulant medications (methylphenidate or lisdexamfetamine) combined with behavioral interventions should be initiated as first-line treatment, while preschoolers aged 4-5 years should receive parent- and/or teacher-administered behavioral therapy first, reserving methylphenidate only for moderate-to-severe dysfunction unresponsive to behavioral interventions. 1

Diagnostic Work-Up

Clinical Assessment Requirements

• Confirm DSM-5 criteria are met with documentation of impairment in more than one major setting (home, school, work) through reports from parents/guardians, teachers, and other clinicians involved in care 2
• Obtain specific information about inattentive symptoms (≥6 symptoms: lack of attention to details, poor sustained attention, poor listening, failure to follow through, disorganization, avoidance of sustained mental effort, losing things, distractibility, forgetfulness) and hyperactive-impulsive symptoms (≥6 symptoms: fidgeting, leaving seat, inappropriate running/climbing, difficulty with quiet activities, excessive talking, blurting answers, difficulty waiting turn, intrusiveness) 3
• Screen for comorbid conditions including anxiety, depression, oppositional defiant disorder, conduct disorder, learning disabilities, substance use disorders, and bipolar disorder before initiating treatment 2, 4
• For adolescents specifically, assess for active substance use and obtain personal/family cardiac history including syncope, palpitations, chest pain, sudden death, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, and long QT syndrome 2, 1

Rating Scales and Monitoring Tools

• Utilize standardized rating scales from parents and teachers (ADHD-RS-IV is the validated primary outcome measure) 5
• Obtain teacher rating scales to assess classroom behavior, work completion, and attention 1
• Consider Adult ADHD Self-Report Scale or Conners Adult ADHD Rating Scales for adults 6

Age-Specific Treatment Algorithms

Preschoolers (Ages 4-5 Years)

Step 1: Behavioral Therapy First-Line

• Initiate evidence-based parent- and/or teacher-administered behavioral therapy as first-line treatment 1
• Parent training in behavior management demonstrates median effect size of 0.55 for improving compliance 1
• Behavioral classroom management shows median effect size of 0.61 for improving attention and decreasing disruptive behavior 1

Step 2: Consider Medication Only If:

• Symptoms have persisted for at least 9 months 2, 1
• Dysfunction manifests in both home and other settings (preschool/child care) 2
• Behavioral interventions have not provided significant improvement and moderate-to-severe functional impairment continues 2, 1

Step 3: Methylphenidate Initiation (If Criteria Met)

• Start at low dose due to slower metabolism in ages 4-5 years 2
• Increase in smaller increments than used in older children 2
• Maximum doses have not been adequately studied in this age group 2

Elementary School-Aged Children (Ages 6-11 Years)

Step 1: Initiate Stimulant Medication + Behavioral Interventions

• Methylphenidate or lisdexamfetamine are first-line pharmacological treatments 1
• Evidence hierarchy: stimulants > atomoxetine > extended-release guanfacine > extended-release clonidine 1, 4
• Extended-release formulations provide once-daily dosing with symptom coverage throughout the school day 1

Step 2: Stimulant Dosing

• For children ≤70 kg: initiate at 0.5 mg/kg/day, increase after minimum 3 days to target of 1.2 mg/kg/day 3
• Maximum daily dose: 1.4 mg/kg or 100 mg, whichever is less 3
• Titrate to maximum benefit with minimum adverse effects rather than strict mg/kg basis 2
• Stimulants can be effectively titrated on a 3-7 day basis due to immediate effects 2

Step 3: Concurrent Behavioral Interventions

• Implement parent training with positive reinforcement, planned ignoring, and appropriate consequences 1
• Coordinate behavioral programs between school and home 1
• Establish 504 Plans or IEPs under "other health impairment" designation 2, 4

Adolescents (Ages 12-18 Years)

Step 1: Obtain Adolescent Assent + Initiate Medication

• Prescribe FDA-approved stimulants with the adolescent's assent as first-line treatment 2, 4
• Adolescent preference strongly predicts treatment engagement and persistence 4
• For adolescents >70 kg: initiate 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 3

Step 2: Address Driving Safety

• Provide medication coverage for symptom control while driving due to increased crash risk and motor vehicle violations 2, 4
• Consider longer-acting or late-afternoon short-acting medications 2

Step 3: Screen for Diversion Risk

• Monitor prescription refill requests for signs of misuse or diversion 2
• Utilize prescription drug monitoring programs (required in most states) 2
• Consider nonstimulant medications (atomoxetine, extended-release guanfacine, extended-release clonidine) if abuse potential is a concern 2

Step 4: Add Behavioral Therapy

• Strongly consider adding behavioral interventions to address functional impairments that medication alone does not resolve 4
• Cognitive/behavioral treatments demonstrate small-to-medium improvements for parent-rated ADHD symptoms and co-occurring emotional/behavioral symptoms 4

Medication Selection and Dosing

First-Line: Stimulants

Methylphenidate or Amphetamines (Lisdexamfetamine)

• Strongest evidence base with largest effect sizes for reducing ADHD core symptoms 1, 4
• More than 70% of children respond to one stimulant at optimal dose with systematic trial 2
• Common side effects: decreased appetite, sleep disturbances, increased blood pressure/pulse, headaches 1
• Monitor height, weight, pulse, and blood pressure at each visit 1
• Growth deceleration seen only for first 2 years, in range of 1-2 cm 2

Second-Line: Atomoxetine

Non-Controlled Alternative

• For children/adolescents ≤70 kg: initiate 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) 3
• For adolescents >70 kg and adults: initiate 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 3
• Can be discontinued without tapering 3
• Preferred when substance use concerns exist or for concurrent anxiety/depression 2, 6

Third-Line: Extended-Release Guanfacine

Alpha-2 Agonist with Significantly Smaller Effect Sizes

• Starting dose: 1 mg once daily 1
• Titrate by 1 mg per week based on response and tolerability 1
• Target dose range: 0.05-0.12 mg/kg/day or 1-7 mg/day 1
• Monitor blood pressure and heart rate at baseline and each follow-up visit due to modest decreases 1
• Must be tapered gradually (reduce by 1 mg every 3-7 days) rather than abruptly discontinued to prevent rebound hypertension 1
• Can be maintained at 1 mg daily as adjunctive therapy to stimulants if oppositional symptoms persist 1

Fourth-Line: Extended-Release Clonidine

• Similar alpha-2 agonist profile to guanfacine with smallest effect sizes 1
• Requires same cardiovascular monitoring and tapering precautions 1

Medication Titration Protocol

Systematic Titration Approach

• Alert parents that changing medication dose and occasionally changing medications may be necessary for optimal management 2
• Process may require a few months to achieve optimal success 2
• Schedule follow-up in 2-4 weeks after initiating stimulants, with benefits expected within 4 weeks 1
• Obtain teacher rating scales at follow-up to assess classroom behavior and work completion 1

Dosing Adjustments for Special Populations

Hepatic Impairment (Atomoxetine)

• Moderate hepatic insufficiency (Child-Pugh Class B): reduce initial and target doses to 50% of normal 3
• Severe hepatic insufficiency (Child-Pugh Class C): reduce initial and target doses to 25% of normal 3

CYP2D6 Poor Metabolizers or Strong Inhibitor Use (Atomoxetine)

• Children ≤70 kg: initiate 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: initiate 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

Combination Treatment Strategy

When to Combine Medication + Behavioral Therapy

• Combined treatment allows for lower stimulant dosages, potentially reducing adverse effects 2, 1
• Combination offers greater improvements on academic and conduct measures compared to medication alone 2
• Parents and teachers report significantly greater satisfaction with combined treatment 2, 1
• Particularly beneficial when ADHD is comorbid with anxiety or child lives in lower socioeconomic environment 2

Sequencing Combined Treatments

• For preschoolers: behavioral therapy first, add medication only if inadequate response 1
• For elementary school-aged children: initiate both concurrently 1
• For adolescents: medication with adolescent's assent, add behavioral therapy as adjunctive treatment 4

Monitoring and Maintenance

Regular Monitoring Schedule

• Monitor medication efficacy systematically at regular intervals 2
• Assess for adverse effects at each visit: appetite, sleep, cardiovascular parameters, growth 1
• For stimulants: monitor height, weight, pulse, blood pressure at each visit 1
• For guanfacine/clonidine: monitor blood pressure and heart rate at each visit 1
• Utilize prescription drug monitoring programs for adolescents to identify diversion 2

Long-Term Management

• ADHD should be managed as a chronic condition requiring ongoing care 4
• Periodically reevaluate long-term usefulness of medication 3
• Maintenance treatment is generally needed for extended periods 3
• For adolescents: begin transition planning to adult care at approximately age 14 4

Non-Pharmacologic Interventions

Behavioral Interventions

Parent Training in Behavior Management

• Techniques include positive reinforcement, planned ignoring, appropriate consequences 1
• Consistently applied rewards and consequences 1
• Median effect size of 0.55 for improving compliance with parental commands 1

Behavioral Classroom Management

• Median effect size of 0.61 for improving attention to instruction and decreasing disruptive behavior 1
• Coordinate behavioral programs between school and home to enhance treatment effects 1

Training Interventions for Adolescents

• Target skill development through repeated practice with performance feedback 4
• Particularly effective for addressing disorganization of materials and time management 4

Educational Supports

• Educational interventions and individualized instructional supports are necessary components of any treatment plan 1, 4
• Establish 504 Rehabilitation Act Plans or IEPs under "other health impairment" designation 2, 1
• Accommodations may include extended time for tests, reduced homework demands, ability to keep study materials in class, provision of teacher's notes, untimed college-readiness tests 2, 4

Critical Pitfalls to Avoid

Diagnostic Pitfalls

• Do not mistake behavioral reactions to psychosocial stressors or academic challenges as requiring medication changes alone 1
• Rule out alternative explanations: thyroid disease, mood disorders, substance use disorders, medication adverse effects (steroids, antihistamines, anticonvulsants, caffeine, nicotine) 7
• Screen for bipolar disorder, mania, or hypomania before initiating atomoxetine 3

Treatment Pitfalls

• Avoid inadequate stimulant trials that lead to premature conclusions about treatment failure 1
• Do not titrate stimulants strictly on mg/kg basis; titrate to maximum symptom control without adverse effects 2
• Never abruptly discontinue guanfacine or clonidine due to rebound hypertension risk 1
• Do not prescribe medication for children whose symptoms do not meet DSM-5 criteria for ADHD 2

Monitoring Pitfalls

• Reassess the original diagnostic formulation if response to adequate treatment is poor, considering unrecognized comorbidities, psychosocial stressors, or poor treatment adherence 1, 4
• Do not neglect cardiovascular monitoring for stimulants (increases in BP/HR) or alpha-2 agonists (decreases in BP/HR) 1
• For adolescents, do not overlook signs of medication diversion or misuse 2

Special Circumstances

• Treatment of ADHD may resolve coexisting oppositional defiant disorder or anxiety in some cases 2
• Some co-occurring conditions require treatment in addition to ADHD treatment 2
• For adolescents with active substance use, refer to subspecialist for consultative support before initiating medication 2