The 2019 AAP report recommends the following guidelines for treatment:
- ADHD is a chronic condition, and as such, PCPs should follow the management principles of the chronic care and medical home models.
- First-line treatment for preschool children should be parent training in behavior management and classroom behavioral interventions.
- Elementary and middle school-aged children should receive US Food and Drug Administration (FDA)-approved medications, parent training, and classroom interventions, as well as an evaluation for an Individualized Education Program (IEP).
- Adolescents should receive FDA-approved medications (with adolescent’s consent), as well as behavioral training and classroom interventions/instructional supports.
- Medications for ADHD should be titrated to achieve maximal benefits with minimal side effects.
- If the PCP is trained or experienced in the diagnosed comorbid disorders, they should initiate treatment; otherwise, they should refer the patient to an appropriate specialist.13
Behavioral and Psychological Interventions
Studies have confirmed that typical ADHD behaviors in children negatively affect parenting styles and cause family stress. These behaviors affect school performance, work, and social aspects of life. Impulsivity and poor emotional regulation lead to difficulty following rules, aggression, tantrums, and general noncompliance.23
Though the evidence is mixed, a multimodal approach to treatment of ADHD continues to be recommended. In younger children, group-based behavioral interventions (based on social learning theory), positive parenting, and parent behavioral training are recommended before the initiation of FDA-approved medications.13
Behavioral parent training involves 8 to 12 group or individual sessions focusing on learning styles, developing a reward and consequence system, understanding the antecedents to behaviors, and teaching children to better communicate their needs. Behavioral parent training results in less severe episodes of noncompliance around chores, mealtimes, homework, and peer interactions.23
Although behavioral parent training is associated with a reduction in ADHD symptoms, challenges with childcare and transportation can make it difficult for working patients to complete traditional face to face sessions.24 Online parent training has proven effective and provides additional options for parents.24
Adults with ADHD also benefit from a multimodal approach to therapy. The Canadian ADHD Resource Alliance Practice Guidelines indicate that it is critical to set individuals up for success in work environments.25 The guidelines recommend cognitive behavioral therapy and mindfulness training. With foundations based on the relationships among cognition, emotion, and behavior, cognitive behavioral therapy has shown efficacy when specific focus is placed on time management and organizational skills. Mindfulness training, including meditation, teaches skills of focusing on the present and inhibiting distractions and intrusive thoughts. Mindfulness also has been shown to improve mood and anxiety in children, adolescents, and adults with ADHD, with improvements maintained over time.25
When choosing a pharmacological treatment, clinicians are faced with multiple and conflicting treatment guidelines and algorithms. Providers are expected to synthesize and evaluate multiple factors: efficacy of the drug in reducing the target symptoms and improving global clinical functioning, effects on comorbidities, tolerability, formulation, long-acting vs short-acting agents, effects on weight and blood pressure, safety, and cost. A table of FDA-approved medications for ADHD can be found at https://www.empr.com/home/clinical-charts/adhd-treatments/.
Although the FDA has approved both stimulant and nonstimulant medications for the treatment of ADHD in children and adolescents, psychostimulants are recommended as first-line treatment.13 A 2018 meta-analysis supported the use of methylphenidate as a first-line treatment of ADHD in children and adolescents.26 In a 2020 meta-analysis, the authors reported that discontinuation of medications in children and adolescents was associated with a decrease in quality of life.27
It should be noted that not all stimulants work the same way, and several different medications may need to be tried before an effective agent is found. Central nervous system stimulants are associated with appetite suppression, weight reduction, and growth delay in children and adolescents.28 Therefore, height and weight must be routinely monitored. Implementing drug holidays during weekends and school breaks as well as encouraging high-calorie snacks and timing dosing with or after meals/ snacks may be effective strategies to prevent weight loss.28
Although amphetamines are the first-choice medication for treatment of ADHD in adults,26 comorbidities and contraindications may alter initial treatment decisions. A history of heart attack, and electrical/structural abnormalities or arrhythmia, hypertension, stimulant use disorder, angle closure glaucoma, and pregnancy are contraindications for treatment with stimulants. Significant comorbidities such as psychosis, SUD, severe mood disorder, and bipolar disorders affect the overall risk assessment and are given priority in treatment decisions.25
Although it is common for some depressive symptoms or anxiety to occur secondary to ADHD, these conditions usually will improve with ADHD treatment and may not need additional pharmacologic strategies. When stimulants are contraindicated, it is common for providers to prescribe bupropion, a dopamine and norepinephrine reuptake inhibitor, to treat ADHD in adults.25