Attention-Deficit/Hyperactivity Disorder Management

Last updated: 18 May 2026
Reviewed by

Evaluation

Attention Deficit Hyperactivity Disorder_Management 1Attention Deficit Hyperactivity Disorder_Management 1




Associated Conditions of Attention-Deficit/Hyperactivity Disorder (ADHD) (≥1 of the following):

  • Learning disabilities (eg cognitive impairment, specific learning disorder, motor coordination problems, memory or auditory discriminatory problems)
  • Speech and/or language delays
  • Anxiety disorder
  • Mania-bipolar disorder
  • Autistic disorder
  • Conduct disorder
  • Depression
  • Psychosis
  • Oppositional defiant disorder
  • Family and/or social problems
  • Other medical problems (eg iron deficiency, lead toxicity, Tourette’s syndrome, tics, sleep apnea)


Further Assessment

Increased prevalence of ADHD may be seen in those born preterm or with low birth weight; with epilepsy, acquired brain injury, history of substance misuse, or family history of ADHD; and individuals who are looked after. Female patients are more likely to be underdiagnosed or misdiagnosed with a different mental health or neurodevelopmental disorder.

Other components of evaluation include: Parent or caregiver interview (eg medical history including obstetric and perinatal history, developmental history, family history, co-existing conditions, current drug therapy, parent or caregiver’s mental health); patient interview; questionnaires; psychoeducational assessment; clinical exam (eg physical [height and weight] or medical exam, vision and hearing test); and ancillary evaluation (psychiatric, psychological), when necessary.

ADHD-specific scales or narrow-band scales may be used to provide additional supportive evidence in establishing the diagnosis of ADHD as well as to monitor symptom progress. Focus directly on the symptoms. Preschool children may be assessed using the Conner Comprehensive Behavior Rating Scales and the ADHD Rating Scale. Broad-band rating scales may be used to identify associated behavioral conditions and evaluate psychological functioning. 

Principles of Therapy

Medications should only be started by an attention-deficit/hyperactivity disorder (ADHD) specialist. Pharmacotherapy for children <5 years old may be started only when advised by an ADHD specialist. Pharmacotherapy for children >5 years old may be started only when a baseline assessment has been done and there is persistent significant impairment in at least one area of function after the implementation and review of environmental changes. Prior to starting pharmacotherapy in adolescents, it is important to assess them for symptoms of substance abuse.

Inform the parents on the initial titration process and the usual duration of the process. Medications should be titrated to maximum doses that control the symptoms with minimum or no adverse effects. Slower dose titration and more frequent treatment monitoring are indicated in children with ADHD with mental or physical health conditions (eg acquired brain injury, epilepsy, or cardiac disease) or neurodevelopmental disorders. Treatment failure may be a sign of incorrect or incomplete diagnosis; thus, the following are recommended: Repeat diagnostic evaluation, check for adherence to the treatment plan, and children aged ≥5 years should be referred to an ADHD specialist if unresponsive to treatment with ≥1 stimulant and one non-stimulant agent.

Factors to consider when choosing a medication include the presence of comorbid conditions. Treatment of ADHD may sometimes resolve the coexisting condition; however, there are also cases that comorbid conditions should be treated in addition to ADHD management. Coexisting medical conditions may have contraindications for other specific medications. Perform a cardiovascular evaluation in these patients. Patients with known structural heart problems should be seen by a cardiologist before being given stimulants and/or Atomoxetine. Other factors include preferences of the child and/or his or her parent or guardian, potential issues regarding adherence to the medication regimen (eg mental health or social circumstances), current medications or adverse effects of drugs, potential for drug diversion (where the drug is forwarded on to others for non-prescription uses) or misuse, and cost of medication.

Pharmacological therapy

Attention Deficit Hyperactivity Disorder_Management 2Attention Deficit Hyperactivity Disorder_Management 2




Stimulant Medications

Stimulant medications are considered the first-line therapy and should be combined with behavioral training (BT). For patients 6-11 years of age, stimulants and/or BT are recommended. This is predominantly attributed to binding with the dopamine transporter and subsequent inhibition of dopamine reuptake resulting in increased levels of extracellular dopamine.

Studies have documented the efficacy of reducing the core symptoms of attention-deficit/hyperactivity disorder (ADHD), which is hyperactivity, inattention, and impulsivity. Stimulant medications also improve the child’s ability to follow rules, decrease over-reactivity of emotions, and eventually lead to improved relationships. Most patients, though improved, do not show fully normal behavior. Most controlled studies have been based on short-term use. Efficacy has been proven for at least up to 14 months of use.

Careful and systematic dosing titration should be done to determine the optimal dosing for an individual. Titration can be done on a 3- to 7-day basis. All types and dosage forms have been shown to have equal efficacy but try considering immediate- and modified-release stimulant preparations for optimal effect. An individual patient may respond to one type or form but not to another, and effects vary from one person to another. Consider another stimulant if one stimulant does not achieve desired results. Alternative agents should be considered when ≥2 stimulants have been tried without success. Specialist referral may be needed. Any history or physical examination changes during treatment should warrant consultation with a cardiologist.

Dexmethylphenidate

Dexmethylphenidate is a central nervous system (CNS) stimulant indicated for the treatment of ADHD. This is an active enantiomer of Methylphenidate. This is considered twice as potent as racemic Methylphenidate. Although Dextroamphetamine is the only drug approved by the United States Food and Drug Administration (US FDA) for patients <6 years of age, there is insufficient evidence to support its safety and efficacy in this age group; hence, it is not recommended by the American Academy of Pediatrics (AAP) at this time in children age 3-5 years. Dexmethylphenidate is considered in children aged ≥5 years who are responsive to Lisdexamfetamine therapy but are intolerant of its prolonged effect.

Lisdexamfetamine

Lisdexamfetamine is a prodrug of Dextroamphetamine. This is therapeutically inactive until metabolized in the body. Lisdexamfetamine is considered in children aged ≥5 years unresponsive to 6-week optimum Methylphenidate therapy.

Methylphenidate



Attention Deficit Hyperactivity Disorder_Management 3Attention Deficit Hyperactivity Disorder_Management 3



Methylphenidate is the first-line agent for children aged ≥5 years. Only preschool-aged patients who have moderate-severe ADHD are considered for pharmacotherapy. This may be used if behavior interventions do not provide significant improvement. There is moderate evidence to support the efficacy and safety of Methylphenidate in this age group.

Alternative Agents

Clinicians should seek specialist referral if unfamiliar with the use of Atomoxetine, Bupropion, Clonidine, Guanfacine and TCAs. Atomoxetine, extended-release Guanfacine and extended-release Clonidine are administered instead of stimulants if there is an issue with possible abuse or diversion of the drug, if stimulant-related tics develop, and if preferred by parents. Extended-release Guanfacine and extended-release Clonidine may be given as an adjunctive therapy in patients who partially respond to stimulants. Atomoxetine or Guanfacine may be given to children aged ≥5 years if they are intolerant of Methylphenidate or Lisdexamfetamine, or are unresponsive to separate Methylphenidate and Lisdexamfetamine 6-week trial therapies. Lipirinen, an FDA-approved medical food containing phosphatidylserine conjugated to omega-3 fatty acids, is found in studies to have reduced ADHD symptoms in patients who have completed 3 months of therapy.

Atomoxetine

Atomoxetine is a US FDA-approved non-stimulant agent for use in ADHD. This has been shown to be more effective than placebo, in short and longer term (at least 2 years). Atomoxetine may be as effective as stimulant medications, but more studies are needed. Atomoxetine has demonstrated efficacy in reducing core symptoms. Long-term safety is yet to be determined. This is not yet approved for use in preschool-aged patients and not recommended by the US FDA in patients with serious heart problems.

Bupropion 



Attention Deficit Hyperactivity Disorder_Management 4Attention Deficit Hyperactivity Disorder_Management 4



Bupropion has been shown to have efficacy in adults with ADHD in small randomized clinical trials. This is used off-label in adults who have not responded to first-line agents.

Clonidine

Clonidine may be used in patients 6-11 years of age, either alone or combined with behavioral training (BT). This has been shown to reduce core symptoms. This may be more effective for extensive impulsivity/aggression or for tics and may take 6-8 weeks to see effect. Clonidine has been associated with adverse cardiovascular effects. This is not yet approved for use in preschool-aged patients.

Guanfacine

Guanfacine has demonstrated efficacy in reducing core symptoms. This is less sedating than Clonidine and may be an alternative for children with tics. This may take 6-8 weeks to see the effect. Decrease the dose or change to another ADHD medication if the patient is experiencing orthostatic hypotension on Guanfacine. This is not yet approved for use in preschool-aged patients.

Tricyclic Antidepressants (TCAs)

Only Desipramine and Imipramine have been studied extensively; others include Amitriptyline, Nortriptyline and Clomipramine. These may only be administered when patients have not responded to licensed drugs for ADHD. Tricyclic antidepressants have a larger potential effect on behavior compared to attention or concentration deficits. There is a narrower margin of safety than stimulants and more potential adverse reactions than stimulants.

Viloxazine

Viloxazine is a selective norepinephrine reuptake inhibitor indicated for adults with ADHD who are intolerant or with contraindications to stimulants.

Nonpharmacological

Develop Management Plan

Specific target outcomes should be defined to guide the management of ADHD. The primary goal is to maximize functions. Examples of target outcomes include improvements in relationships, a decrease in disruptive behaviors, improved academic performance, etc. Goals, treatment planning, and decision-making should be reviewed with all involved (eg parent/caregiver, patient, and school).

Psychosocial Treatment

Parent/Caregiver and Patient Education

Provide information about attention-deficit/hyperactivity disorder (ADHD) to the parent or caregiver. Identify and eliminate the trigger factors that cause inattention, hyperactivity, or impulsivity. Provide information about the disorder, common features, neurologic mechanisms, and associated conditions. Discuss the expected clinical course and intervention strategies, including risks and benefits. Review how it can affect behavior, learning, social skills, confidence, and family life. Inform the parent or caregiver about other ways of learning management skills through support groups, advocacy groups, and parenting skills training.

The parent or caregiver is encouraged to: Spend at least 10-15 minutes with the child; assure the child that he or she is not the problem but his or her behavior; have clear, concise household rules with the use of reward and punishment; limit giving 1-2 clear instructions at a time and have the child be able to repeat the instructions back; allow the child to experience consequences of actions as consistent and predictable; give appropriate disciplinary measures for challenging behavior; have consistent schedules and structure in the child’s everyday activities; have a private, quiet place for homework or projects; allow the child to have choices; use time-out to contain the child's emotional dysregulation; and discuss any concerns that they may have on themselves (particularly if the parent or caregiver has ADHD) and on the child.

Parent skills training may be done through reading books and individual counseling or in formal classes. Family therapy may be advised for families with extremely disruptive children or the presence of significant family pathology thought to be related to the child’s presenting problem. For the child, tailor ADHD education to age, gender, and educational level, and include discussion of the child’s strengths and attributes. A referral to a child psychiatrist or ADHD specialist may be needed if there is at least moderate impairment with the child’s persisting behavioral problems. If a child with ADHD has a coexisting condition, the parent or caregiver should encourage relevant healthcare professionals to provide a treatment plan and feedback.

School Personnel Education



Attention Deficit Hyperactivity Disorder_Management 5Attention Deficit Hyperactivity Disorder_Management 5




Do not assume that the teacher has knowledge of ADHD. Provide information relevant to the teacher or school about how ADHD may affect the child in the classroom. This should include intervention strategies and environmental modifications for dealing with behavior issues.

School personnel is encouraged to: Have an orderly and predictable classroom; have clear and concise rules; have classroom strategies (eg written notices for homework and schedules); have very interesting multisensory learning activities; use positive reinforcers of good behavior; establish parent-teacher communication; inform parents regarding programs on parent education and training; help students with self-monitoring, self-reinforcement, and development of compensatory or adaptive strategies; and provide feedback to the child and his/her parent or caregiver and physicians. 



Attention Deficit Hyperactivity Disorder_Management 6Attention Deficit Hyperactivity Disorder_Management 6


Behavioral Training (BT)

Parent- and/or teacher-administered behavioral training (BT) is the first-line treatment in preschool-aged children (ie 4-5 years of age). In patients 6-11 years of age, BT may be used in combination with stimulants, Atomoxetine, Guanfacine and Clonidine. In patients 12-18 years of age, BT may be suggested as part of pharmacotherapy. Provide management strategies to modify the physical and social environment to help modify behavior.

Cognitive BT is a problem-solving strategy that helps patients stop and think before acting. This is used to treat impulsive patients with non-self-controlled behavior and problem-solving deficits; and it focuses on management skills (ie time management). Consider giving cognitive behavioral therapy to young patients in whom there is still significant impairment in at least one area of function despite benefiting from medical therapy. Mindfulness training is a strategy aimed for one to be conscious of his/her thoughts and behavior. Train parents or caregivers and teachers with specific techniques for improving behavior, such as positive reinforcement, time-out, response cost, and token economy. Group-based behavioral interventions are focused on peer relationships or interactions.

Evidence of the effectiveness of BT comes from varied studies. Long-term positive effects of BT are still to be determined. The large variety in behavioral therapy and outcome measures makes meta-analysis difficult. The majority of studies comparing BT alone versus stimulant medications show stimulants to be more effective. Based on a study, combining BT with medication showed no more efficacy in reducing core symptoms than medication alone. Combination therapy also allowed the use of lower drug dosages, hence reducing the risk of adverse effects. Most patients, though improved, do not show fully normal behavior. For families who refuse pharmacological therapy, BT alone has been found to be more effective than no treatment.

Social Skills Training

Social skills training is used to teach children practical interpersonal skills in a safe setting. Skills taught include maintaining eye contact, strategies for initiating and maintaining conversations, and remembering to share and cooperate.

Psychological Interventions

Psychological interventions are different from behavioral interventions. This is directed at a child. Psychological interventions are designed to change a child's emotional status or thought patterns. Documented efficacy of psychological treatment of children is lacking.