Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
parent training in behavior management (PTBM) and/or behavioral classroom intervention + psychoeducation
There is international consensus that parent training in behavior management (PTBM) and/or behavioral classroom interventions are recommended first line in this age group.[90][91] The aim of parent training is to help parents improve their understanding of the child's behavior; it also teaches skills to manage it better (such as directive communication skills, reinforcing positive behaviors, time out techniques, establishing a home token economy, and anticipating noncompliant behaviors).
A formal diagnosis of ADHD is not required before recommending parent training given that it has documented effectiveness for problematic behaviors regardless of etiology; parents should be advised not wait for an ADHD diagnosis before initiating the treatment.[90] One randomized controlled trial looking at pharmacologic treatment for preschool children with an established diagnosis of ADHD found that, following parent training, around one third of children had experienced a significant improvement in symptoms to the extent that they did not require medication at that time.[119] The Incredible Years (IY) basic parent training (PT) program has been shown to be a valuable intervention for preschool children with early signs of ADHD.[120]
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If the child attends preschool, behavioral classroom interventions are also recommended.[90]
Psychoeducation is a first-line intervention for all patients. The patient and family should be educated about symptoms, typical course, and potential treatments. These discussions should include coaching about educational services and individualized education plans. Discussions can also include referral to support and advocacy organizations. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) Opens in new window Attention Deficit Disorder Association Opens in new window Online resources and toolkits such as parent handouts and rating scales are available. Vanderbilt ADHD diagnostic scales Opens in new window ADDitude magazine Opens in new window Psychoeducation should also include treatment options and should consist of clear, nontechnical language and evidence-based recommendations.
stimulant (methylphenidate or amphetamine)
Treatment recommended for SOME patients in selected patient group
A key difference in practice internationally is that UK guidance recommends starting nonpharmacologic options alone first, particularly for children with milder symptoms of ADHD, whereas US guidance recommends consideration of medication immediately following a diagnosis.[90][91]
Stimulant medications (drugs based on methylphenidate and amphetamine) are the first-line agents of choice if pharmacotherapy is being considered.
Amphetamines and methylphenidate have been shown to be effective at improving the core symptoms of ADHD compared with placebo, but are associated with adverse events such as sleep problems, dry mouth, nausea, decreased appetite, growth suppression, and small increases in pulse and blood pressure.[117][119][124][125][126][131][136]
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Given the euphorigenic and performance-enhancing effects of stimulants, healthcare professionals should be alert to the signs of misuse and/or diversion.[112] The FDA has noted concerns about nonmedical use of prescribed stimulants, particularly with respect to patients sharing their prescribed stimulants with family members and peers.[135] Stimulants may also be associated with rare but serious adverse effects (e.g., psychosis and serious adverse cardiac events) although the evidence on this is equivocal.[132][133][137][140]
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[Evidence C] The possibility of a small increased risk of serious adverse events raises the importance of careful risk-benefit analysis, particularly in children with milder symptoms of ADHD.
UK guidance recommends starting with methylphenidate if pharmacologic treatment is required.[91] US guidance lists stimulants as the first-line option but does not specify a particular stimulant to try first.[90] Both amphetamines and methylphenidate have much in common and the differences in efficacy and adverse effects are generally minimal, patient-specific, and difficult to predict before a trial.[127] Individual patients may respond to one and not the other due to differences in their mechanism of action as well as differences in formulation (e.g., variable delivery, absorption).[32][124][125] One large network meta-analysis found that methylphenidate and amphetamines both had moderate-to-large effect sizes when symptomatology was rated by clinicians and teachers. Taking adverse effects into account, the analysis found that the medication with the best benefit-to-risk ratio in children and adolescents with ADHD was methylphenidate.[117]
Long-acting preparations offer greater convenience (once-a-day dosing), privacy (do not need to take at school), and compliance, and are preferred first-line in the majority of cases.[112] When necessary, regimens can be sculpted: for instance, a long-acting stimulant in the morning, followed by a short-acting stimulant in the afternoon when the effect of the morning dose is wearing off. Prescribers should note that there are differences in long-acting formulations of methylphenidate in terms of dosing frequency, administration with food, amount and timing of the modified-release component, and overall clinical effect. It is important to follow specific dosage recommendations for each formulation, and to use caution if switching from one to another long-acting preparation of methylphenidate.
If prescribing medication for ADHD within the context of suspected or confirmed substance disorder, select medications with lower liability for misuse. Stimulant drugs may still be considered as first-line options, although preparations with lower liability for misuse, such as extended-release or transdermal formulations, are recommended.[110][172][173] As with any clinical decision, the key is a careful risk:benefit analysis. Determine whether it is reasonable to initiate or continue stimulant pharmacotherapy, taking into account individual patient factors. A number of different amphetamine medications are available with variable half-lives; one example of an amphetamine formulation with lower misuse potential is lisdexamfetamine. There is some evidence to suggest that methylphenidate has lower misuse potential compared with amphetamines.[110] Identification of suspected or confirmed substance use disorder requires immediate brief intervention and referral to an addiction or mental health specialist. Expert consensus typically states that treatment should address addiction first, before going on to address ADHD.[110][172] Once substance use problems have been stabilized, simultaneous and integrated treatment of ADHD and the substance use disorder using a combination of pharmaco- and psychotherapy is recommended for situations where treatment is safe.[173] For patients with substance use disorder who are prescribed stimulants, close monitoring and anticipatory discussion with the child and their family is paramount. Monitoring strategies include pill counts, drug testing, frequent clinical contact and, in locations such as the US, frequent electronic database checks.[173] Consider arranging for a parent, health professional (e.g., trained school nurse), or other trusted adult to directly observe administration of the medication, and counsel families on the importance of safely storing and restricting access to controlled medications.[173] If the risks of stimulant medication outweigh the benefits, consider prescribing a nonstimulant medication instead, but note that evidence of efficacy against symptoms of ADHD is lower.[173] See: 3rd and 4th line options.
Stimulant medications are the first-line pharmacologic agents even in the presence of a co-occuring tic disorder.[91][123] Although concerns have been noted that stimulants may cause or exacerbate tics, this is not supported by the available evidence.[145][175] If tics emerge following stimulant initiation or increase and are experienced as unacceptable, options include a trial of discontinuation of the stimulant with later rechallenge, addition of an intervention to address tics, for example comprehensive behavioral intervention for tics (CBIT) or a tic-reducing medication, or a change to a nonstimulant ADHD medication.[110]
Regular contact (e.g., in person or via phone, video call, or email) is recommended for all patients during the titration period, including both informal and formal (rating scale) assessments of symptoms and functioning.[112]
There are many different brands of each stimulant available, and dose depends on the brand and formulation used.
Primary options
methylphenidate: consult specialist for guidance on dose
OR
dexmethylphenidate hydrochloride: consult specialist for guidance on dose
OR
dextroamphetamine/amphetamine: consult specialist for guidance on dose
OR
lisdexamfetamine: consult specialist for guidance on dose
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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