A Guide to Treatment for ADHD in Children and Adolescents

The proportion of U.S. children and adolescents age 2 to 17 years diagnosed with attention deficit hyperactivity disorder (ADHD) is estimated to be about 8%.[1] Of those ADHD cases, approximately 30% are treated with medication only, 15% are treated with behavioral therapy only, 32% receive a combination of the two and 23% receive neither treatment.

The number of different treatment options for ADHD can be overwhelming. Moreover, a recent systematic review of over 300 studies “found convincing evidence of ADHD overdiagnosis and overtreatment in children and adolescents.”[2] Accordingly, below we summarize the ADHD diagnosis process and evaluate available therapeutic options for managing it.

An accurate diagnosis

ADHD (which cannot be diagnosed by a blood, brain-imaging or physiological test[3]) is a persistence of inattentive and hyperactive or impulsive behaviors that interfere with a child’s ability to function or develop across multiple settings and scenarios.[4] Such problems in isolation, however, are not sufficient to warrant the diagnosis. The diagnosis should be made by licensed clinicians, ideally including a physician with ample experience diagnosing and treating youths with ADHD.

The specific diagnostic criteria for ADHD include:[5]

• The symptoms cause significant difficulties in functioning in more than one major setting, such as at home and at school.
• The significant difficulties have lasted at least six months.
• The symptoms started before age 12. If the symptoms appear for the first time in a teen or adult, they are likely due to a different problem, such as substance abuse or anxiety.[6]
• The symptoms occur often and seem inappropriate for the child’s age.

Don’t hesitate to seek a second opinion from another specialist with ADHD experience (this could be a child neurologist, psychiatrist or psychologist).

Behavioral therapy and skills training

Both drug and nondrug therapies can be used to treat children and adolescents with ADHD, with use of either or both depending on the child’s age.[7]

According to the October 2019 American Academy of Pediatrics (AAP) clinical practice guideline for ADHD, effective psychosocial therapies for the disorder include behavioral therapy and skills-training interventions. Behavioral therapies include those that educate parents and teachers to help children overcome some of the negative behaviors associated with ADHD such as interrupting, aggression, failure to complete tasks and noncompliance with requests.[8] The AAP guideline further states that most studies comparing behavioral therapy with stimulant medication show that although medication is more effective in the short term, behavioral therapy effectiveness is uniquely persistent after the treatment is halted, and parents express more satisfaction with the effects of behavioral therapy.[9]

Skills training is delivered directly to children and adolescents with ADHD and involves repeated practice and performance feedback to overcome common ADHD-related deficits, targeting areas such as organization and time management (for example, use of a planner) as well as social skills instruction. According to the AAP guideline, the research-based evidence that these training interventions are effective is less developed than that available for behavioral interventions.[10]

Drug treatment for ADHD

Stimulants for many years have been the most widely used medications to treat ADHD, with approximately 70-80% of children prescribed such medications experiencing a reduction in symptoms.[11] However, stimulants also have many adverse effects, including appetite suppression, abdominal pain, reduced rate of growth, headaches and sleep disturbance.[12] Rarer but serious adverse effects include hallucinations, other psychotic symptoms and possible increased risk of suicide.[13],[14],[15],[16] Drug treatments are especially unacceptable if ADHD is wrongly diagnosed or if behavioral therapies have not been attempted.

Stimulants approved by the Food and Drug Administration (FDA) for treating ADHD include methylphenidate (ADHANSIA, APTENSIO, CONCERTA, COTEMPLA, DAYTRANA, JORNAY, METADATE, METHYLIN, QUILLICHEW, QUILLIVANT, RITALIN), dexmethylphenidate (FOCALIN), and various amphetamines such as dextroamphetamine (DEXEDRINE), amphetamine sulfate (EVEKEO), dextroamphetamine-amphetamine salts (ADDERALL, MYDAYIS) and lisdexamfetamine (VYVANSE). We have designated dexmethylphenidate and lisdexamfetamine as Do Not Use and the rest as Limited Use.

Stimulant ADHD drugs are controlled substances that have special restrictions when prescribed because they can be abused or lead to addiction. When stimulants are used, parents should monitor their children (especially adolescents) for signs of misuse and diversion, including the need for frequent refills and negative behavioral changes.

Stimulant drugs increase blood pressure and heart rate and can have dangerous and even fatal effects for children and adults who abuse them, as well as those who use the drugs as prescribed but have underlying heart problems.[17],[18],[19] Because of this, the American Heart Association recommends that all children be screened for heart problems before starting treatment with a stimulant and receive assessments for adverse cardiovascular effects at each doctor’s visit while taking these medications.[20]

The FDA has approved four nonstimulants for the treatment of ADHD: the selective norepinephrine reuptake inhibitors atomoxetine (STRATTERA) and viloxazine (QELBREE) and the alpha-adrenergic agonists clonidine (KAPVAY) and guanfacine (INTUNIV).

Viloxazine was approved in 2021, so we have designated it us as Do Not Use for Seven Years.[21] Atomoxetine (designated as Limited Use), clonidine (designated as Do Not Use) and guanfacine (designated as Do Not Use) have lower addiction potential than stimulants but are less effective and less well-studied and have their own adverse effects. Atomoxetine causes drowsiness, nausea, vomiting, decreased appetite and elevated blood pressure and carries a black-box warning for suicidal thinking.[22] Clonidine and guanfacine cause drowsiness, low blood pressure, slow heart rate and fainting and can lead to dangerously high blood pressure if the medication is stopped abruptly.[23],[24]

Alternative therapies

Research suggests that regular exercise improves behavioral and cognitive measures in ADHD patients.[25]

Several other alternative therapies have been suggested for children with ADHD, but none have proven both safe and effective for this condition. Some are less concerning than others, like mindfulness,[26] which is plausibly beneficial or benign for most children.

Other alternative treatments, however, are more questionable. For example, polyunsaturated fatty acid supplements have few adverse effects, but the effectiveness of such supplements on ADHD symptoms is uncertain.[27] Megadoses of vitamins and chelation (using chemicals to remove metals and minerals from the blood) also are not effective and may be harmful.[28]

Treatment for preschoolers

For children age 4 to 6 years, the youngest ages when ADHD can be diagnosed, the mainstay of treatment is behavioral therapy — not drugs.[29] Where behavioral therapy fails, the AAP recommends methylphenidate because this drug has been better-studied in preschool-aged children than other ADHD drugs.[30] However, evidence of this drug’s effectiveness for such young children remains limited, adverse effects are a concern and the drug is not FDA-approved for this age group.[31] We thus recommend against using any drug to treat preschoolers with ADHD.

ADHD in young adults

Recent research indicates that 90% of children with ADHD continue to experience some symptoms into young adulthood, markedly higher than previously estimated.[32] Pooled randomized clinical trial results have recently indicated that adults with ADHD receive limited and low-certainty benefits from stimulant treatment and further may be harmed by such medications.[33] Other pooled scientific analyses showed favorable effects of psychosocial interventions, especially cognitive behavioral therapy, for adults with ADHD.[34]

What You Can Do

Make sure your child has been accurately diagnosed with ADHD before starting treatment. If you are certain your child has ADHD, work with their doctor to develop a treatment plan and follow through on that plan, including behavioral therapy first and stimulant medication for older children if needed. If treatment is not successful, ask your doctor to reevaluate their diagnosis and treatment plan, or seek additional consultation with a specialist.
 

References

[1] S Danielson ML, Bitsko RH, Ghandour RM, et al. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. J Clin Child Adolesc Psychol. 2018;47(2):199-212.

[2] Kazda L, Bell K, Thomas R, et al. Overdiagnosis of attention-deficit/hyperactivity disorder in children and sdolescents: A systematic scoping review. JAMA Netw Open. 2021;4(4):e215335.

[3] Faraone SV, Banaschewski T, Coghill D, et al. The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021 Sep;128:789-818.

[4] Centers for Disease Control and Prevention. Attention-deficit/hyperactivity disorder (ADHD): Symptoms and diagnosis. September 23, 2021. http://www.cdc.gov/ncbddd/adhd/diagnosis.html. Accessed October 11. 2021.

[5] Ibid.

[6] Wolraich ML, Hagan JF Jr, Allan C, et al, Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528.

[7] Krull KR. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. UpToDate. Updated February 3, 2020.

[8] Wolraich ML, Hagan JF Jr, Allan C, et al, Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528.

[9] Ibid.

[10] Ibid.

[11] Centers for Disease Control and Prevention. Treatment of ADHD. September 23, 2021. https://www.cdc.gov/ncbddd/adhd/treatment.html. Accessed October 11, 2021.

[12] Wolraich ML, Hagan JF Jr, Allan C, et al, Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528.

[13] Mosholder AD, Gelperin K, Hammad TA, et al. Hallucinations and other psychotic symptoms associated with the use of attention-deficit/hyperactivity disorder drugs in children. Pediatrics. 2009;123(2):611-616.

[14] Health Canada. ADHD drugs may increase risk of suicidal thoughts and behaviours in some people; benefits still outweigh risks. March 30, 2015. http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2015/52759a-eng.php. Accessed October 11, 2021.

[15] Ramstad E, Storebø OJ, Gerner T, et al. Hallucinations and other psychotic symptoms in response to methylphenidate in children and adolescents with attention-deficit/hyperactivity disorder: a Cochrane systematic review with meta-analysis and trial sequential analysis. Scand J Child Adolesc Psychiatr Psychol. 2018;6(1):52-71.

[16] Novartis Pharmaceutical Corporation. Label: methylphenidate (RITALIN). June 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/010187s093lbl.pdf. Accessed October 11, 2021.

[17] FDA issues stronger warnings for ADHD stimulants; warnings don’t go far enough. Worst Pills. Best Pills News. November 2006.

[18] Greydanus DE, Cates KW, Sadigh N. Adverse effects of stimulant medications in children and adolescents: focus on cardiovascular issues. Int J Adolesc Med Health. 2019;31(3):/j/ijamh.2019.31.issue-3/ijamh-2019-0174/ijamh-2019-0174.xml.

[19] Torres-Acosta N, O'Keefe JH, O'Keefe CL, Lavie CJ. Cardiovascular effects of ADHD therapies: JACC review topic of the week. J Am Coll Cardiol. 2020;76(7):858-866.

[20] Vetter VL. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder [corrected]: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117(18):2407-2423.

[21] Wolraich ML, Hagan JF Jr, Allan C, et al, Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528.

[22] Eli Lilly and Co. Label: atomoxetine (STRATTERA). February 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021411s049lbl.pdf. Accessed October 12, 2021.

[23] Concordia Pharmaceuticals. Label: clonidine extended-release (KAPVAY). February 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/022331s021lbl.pdf. Accessed October 12, 2021.

[24] Takeda Pharmaceutical Company. Label: guanfacine extended-release (INTUNIV). December 2019. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/022037s019lbl.pdf. Accessed October 12, 2021.

[25] Torres-Acosta N, O'Keefe JH, O'Keefe CL, Lavie CJ. Cardiovascular effects of ADHD therapies: JACC review topic of the week. J Am Coll Cardiol. 2020;76(7):858-866.

[26] Wolraich ML, Hagan JF Jr, Allan C, et al, Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528.

[27] Händel MN, Rohde JF, Rimestad ML, et al. Efficacy and safety of polyunsaturated fatty acids supplementation in the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents: A systematic review and meta-analysis of clinical trials. Nutrients. 2021;13(4):1226.

[28] Krull KR. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. February 3, 2020. UpToDate.

[29] Wolraich ML, Hagan JF Jr, Allan C, et al, Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528.

[30] Ibid.

[31] Wigal S, Chappell P, Palumbo D, et al. Diagnosis and treatment options for preschoolers with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2020;30(2):104-118.

[32] Sibley MH, Arnold LE, Swanson JM, et al.; MTA Cooperative Group. Variable patterns of remission from ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry. 2021 Aug 13:appiajp202121010032. doi: 10.1176/appi.ajp.2021.21010032. Epub ahead of print.

[33] Cândido RCF, Menezes de Padua CA, Golder S, Junqueira DR. Immediate-release methylphenidate for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2021 Jan 18;1(1):CD013011.

[34] López-Pinar C, Martínez-Sanchís S, Carbonell-Vayá E, et al. Long-term efficacy of psychosocial treatments for adults with attention-deficit/hyperactivity disorder: A meta-analytic review. Front Psychol. 2018 May 4;9:638.