- In considering the safety of medications, six issues should be keep in mind: 1. severity; 2. duration; 3. frequency, 4. timing; 5. margin of safety and 6. benefit-risk ratio.
- The American Academy of Pediatrics clinical practice guideline, “ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents,” contains the following recommendations for treatment of ADHD in children aged 4 to 18 years:
Two categories of medication are available
Both amphetamines and methylphenidates have very similiar effect and side effect profiles. They have the most extensive evidence for efficacy and safety and are the fist time of medicaiton treatment for ADHD. There are both short acting (immediate release) and extended release formulation
Amphetamines: Dextroamphetamine is the only medication approved by the FDA for use in children younger than 6 years of age. This approval, however, was based on less stringent criteria in force when the medication was approved rather than on empirical evidence of its safety and efficacy in this age group. Most of the evidence for the safety and efficacy of treating preschool-aged children with stimulant medications has been from methylphenidate.
Methylphenidates: Approved for children 6 years and older. There is moderate evidence that methylphenidate is safe and efficacious in preschool-aged children. The American Academy of Pediatrics recommends its use in pre-school-age children but only after first trying parent-and/or teacher-administered behavior therapy. However, its use in this age group remains off-label.
Approved for children 6 years and older
Selective Norepinephrine-reuptake inhibitor (Atomoxetine): The slow onset and round-the-clock effects of atomoxetine necessitate more careful and quantitative monitoring of symptom changes than is usual with stimulants to determine their effects, because these gradual, consistent changes are less evident to caretaker than are the rapid, daily changes observed with stimulants.
Selective α²-adrenergic agonists: indicated for the treatment of ADHD as monotherapy and as adjunctive therapy to stimulant medications. Its effects are also more slowly manifested as in the case of selective norepinephrine-reuptake inhibitor. Clonidine has also been used as a treatment for delayed onset of sleep in children with ADHD.
Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age:
For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function. In areas where 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 (quality of evidence B/recommendation).
For elementary school–aged children (6–11 years of age), the primary care clinician should prescribe US Food and Drug Administration–approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence-based parent- and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation). The evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order) (quality of evidence A/strong recommendation). The school environment, program, or placement is a part of any treatment plan.
For adolescents (12–18 years of age), the primary care clinician should prescribe Food and Drug Administration–approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both
Click ADHD Med Guide for a color guide with pictures of ADHD medications and doses available