Pediatrics:
According to the American Academy of Pediatrics, appropriate treatment of children and youth with ADHD varies depending on the patient’s age.
Preschool-aged children (4–5 years of age):
- Evidence-based parent and/or teacher-administered behavior therapy is the first line of treatment.
- Methylphenidate may be prescribed if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function.
- In areas in which evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment.
Elementary school-aged children (6–11 years of age):
- The primary care clinician should prescribe FDA-approved medications for ADHD and/or evidence-based parent- and/or teacher-administered behavior therapy as treatment for ADHD, preferably both.
Adolescents (12–18 years of age):
- The primary care clinician should prescribe FDA-approved medications for ADHD with the assent of the adolescent and may prescribe behavior therapy as treatment for ADHD, preferably both.
Pharmacologic Therapy:
According to the American Academy of Family Physicians, the mainstay of treatment for ADHD is pharmacotherapy. Options include stimulant and non-stimulant medications. The evidence is particularly strong for stimulant medications and sufficient, but less strong, for non-stimulants such as atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order). Stimulants have been used since the 1930’s, and have a large volume of data to support both their safety and efficacy. For this reason, stimulants are considered first-line pharmacotherapy for children and adults.
Stimulants:
- Effectively alleviate the symptoms of ADHD, including poor attention span, distractibility, impulsive behavior, hyperactivity, and restlessness.
- Improve vigilance, cognition, reaction time, response inhibition, and short-term memory.
- Associated with fewer errors on a driving simulator, and may have a beneficial effect on some aspects of driving- such as less steering variability, slower driving speed, greater use of turn signals, and a fewer impulsive responses (Kolar et al., 2008).
The two main classes of stimulant medications are methylphenidate and dextro-amphetamine. All brand-name stimulants are variations of these two medications. Liquids, chewables, pills, patches, short-acting, intermediate-acting, long-acting, and combinations… All are the same medications with different configurations.
Note: It is important to obtain a careful history of cardiac symptoms; a cardiac family history, particularly of arrhythmias, sudden death, and death at a young age from cardiac conditions; vital signs, and cardiac physical examination prior to starting stimulant therapy. Although more research is needed, there is some indication of increased risk with stimulant therapy.
Contraindications to the use of stimulants in clinical practice include: previous sensitivity to stimulant medications, glaucoma, symptomatic cardiovascular disease, hyperthyroidism, and hypertension. These medications must be used with great care if there is a history of drug abuse.
Links to CMS guides for stimulant therapy:
So, what’s the problem?
Unfortunately, many clinicians are hesitant to prescribe stimulant medications due to lack of experience with treatment of ADHD and/or fear of legal repercussions due to the potential for abuse or diversion of a federally controlled substance.
According to Dr. Rostain, the Medical Director for the Penn Medicine Adult ADHD Program, “As long as you follow sound clinical practice, document what you’re doing and how you made the diagnosis of ADHD, inform the patient of all their treatment options, and provide education about the dangers of misusing the medication, then you’re following standard medical practice, and you won’t have any medical-legal difficulties.”
Hear more from Dr. Rostain and his colleagues below:
Non-Stimulants:
These medications have been shown to be less effective than stimulants in managing ADHD symptoms, but atomoxetine, guanfacine XR and clonidine XR are considered second-line treatments, and are FDA-approved for ages 6 and up. Bupropion is considered a third line agent, and is not yet approved by the FDA for treatment of ADHD (American Academy of Pediatrics, 2016).
These alternative medications are commonly used when stimulants are contraindicated, a more favorable side-effect profile is desired, or based on patient/caregiver preference.
There is a block-box warning on atomoxetine of the possibility of suicidal ideation when initiating medication management.
International Neuropsychiatric Association: Treatment of Adults with Attention Deficit Hyperactivity Disorder
American Academy of Pediatrics: An Algorithm and Explanation for Process of Care for the Evaluation, Diagnosis, Treatment, and Monitoring of ADHD in Children and Adolescents
American Academy of Family Physicians: Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Adults
American Academy of Pediatrics: Non-Stimulant Medications Available for ADHD Treatment
Non-pharmacologic Therapy:
Behavior management treatment: the most commonly used non-pharmacological approaches for treating ADHD and associated impairments.
Behavior management treatment focuses specifically on altering negative parent-child interaction patterns that are often present in families with a child having problem behavior, including ADHD, and child skills training, which focuses on improving social interactions and/or study/organizational skills across multiple settings (Pfiffner & Haack, 2014).
Behavior Management for School Aged Children with ADHD
Cognitive training: working memory training incorporating adaptive schedules that are hypothesized to strengthen ADHD-deficient neuropsychological processes.
Neurofeedback: commonly based on electroencephalography; sensors are placed on the scalp to measure activity, and measurements displayed using video displays or sound. By learning to control their brain activity based on behavioral principles of operant conditioning, it is hypothesized that ADHD patients will learn to regulate the associated attentional states and processes (Catalá-López, Ferrán et al., 2017).
Attention Deficit / Hyperactivity Disorder: A Resource for Professionals 