Pediatric Attention Deficit Hyperactivity Disorder Treatment & Management
- Author: Zainab P Contractor, MD; Chief Editor: Caroly Pataki, MD more...
Medical Care
The 2 major components in the medical care of children with attention deficit hyperactivity disorder (ADHD), previously termed attention deficit disorder (ADD), are behavioral and pharmaceutical therapies. The pharmaceutical component is covered in Medication. In addition, the eMedicine article on adult Attention-Deficit/Hyperactivity Disorder provides extensive tables about the nonstimulant medications.
Most components of behavioral care take place outside of the primary care provider's office. Common components are briefly described below to assist in referral and consultation. Not all components are necessary for every child.
School or education interventions
The age of the child at initial diagnosis and the severity of the symptoms of ADHD (ADD) likely affect the extent to which the child benefits from working with education specialists.
Consultants initially involved with diagnosis and evaluation can also be important in promoting the development of study skills.
Teachers have an important function. Their periodic feedback about the child's school performance through the use of standardized scales, narrative descriptions, and telephone follow-up is generally an indispensable component of ongoing care.
Implementation of academic accommodations and adaptations is often necessary
Psychotherapeutics
For adolescents, ADHD (ADD) coaching, participating in a support group, or both can help normalize the disorder and assist them in obtaining well-focused peer feedback and general information.
Counselors such as psychologists, behavioral developmental pediatricians, clinical social workers, and advanced practice nurses who are well familiarized with ADHD (ADD) can be invaluable to affected children and their families.
Behavioral modification and family therapy are usually necessary for optimal care.
Refer parent(s) for evaluation of ADHD (ADD), if suspected.
Coexisting conditions must be addressed as part of therapy.
Consultations
The timing of consultations depends on the practitioner's degree of knowledge and experience with the evaluation and treatment of ADHD (ADD). Several possible scenarios are described below.
No consultation is necessary
In this scenario, the patient is well known and perhaps has a family member with ADHD (ADD) but no coexistent conditions. The patient has a clear history consistent with ADHD (ADD) without coexistent conditions.
Referral to an ADHD (ADD) specialist, clinic, and/or a psychiatrist or a behavioral developmental pediatrician
The patient may or may not be well known and may have a family member with ADHD (ADD) but no coexistent conditions whose condition. However, the clinician feels the patient must be questioned further about ADHD or coexistent conditions.
The patient may or may not be well known and may have no family history of ADHD (ADD) but has a concerning family history of a mood or anxiety disorder.
The patient may or may not be well known and perhaps has other family members with ADHD (ADD) whose condition is stabilized by medications without problems with coexistent conditions; however, ADHD (ADD) cannot be diagnosed and/or coexistent conditions cannot be ruled out with confidence.
A brief consultation with or referral to an ADHD (ADD) specialist or a psychiatrist or behavioral developmental pediatrician
In this scenario, the patient may or may not be well known to the practitioner, and the condition has been stabilized by medications without problems with identified coexistent conditions. However, the medication either no longer works or has started to cause adverse effects, and the medication cannot be adjusted with confidence.
Referral as soon as possible to a specialist or specialty clinic for drug rehabilitation
In this scenario, a patient is being evaluated and is not taking psychostimulants or is being re-evaluated for current psychostimulants and chemical abuse is noted. If the patient is taking psychostimulants and if the medications are being taken properly, a consultation call to decide whether the stimulants should be continued may be more appropriate than simply stopping them.
Diet
No special diet clearly affects ADHD (ADD). Until this situation changes, a healthy diet with minimal, if any, caffeine should be emphasized. Note that, in children, caffeine is often consumed in the form of chocolate candy, chocolate milk, or "energy" drinks.
While additional studies are warranted to verify the data, the results from one study suggest that a restriction diet may reduce ADHD symptoms in some children; food color additives were identified as a possible association with ADHD symptoms.[5]
Activity
No evidence-based studies have been conducted to elucidate the potential role of physical activity in children with ADHD (ADD). However, anecdotal clinical reports commonly attest to improvements in focus and sleep quality associated with regular physical activity and exercise. In addition, regular physical activity is important in patients with some of the common coexistent conditions (eg, depression, anxiety) and helps improve concentration. Therefore, physical activity is often an important component of therapy.
APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1994:78-85.
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[Best Evidence] Blader JC, Schooler NR, Jensen PS, Pliszka SR, Kafantaris V. Adjunctive divalproex versus placebo for children with ADHD and aggression refractory to stimulant monotherapy. Am J Psychiatry. Dec 2009;166(12):1392-401. [Medline].
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| Medication | Initial Pediatric Dose | Pediatric Dosage Range and Maximum Dose* | Common Pediatric Dose* | Preparations |
| Methylphenidate immediate release (IR) (Ritalin, Methylin, generic) | 2.5-5 mg | 0.1-0.8 mg/kg/dose PO qd to 5 times/d; not to exceed 60 mg/d | 0.3-0.5 mg/kg/dose PO tid/qid | All preparations available as 5-mg, 10-mg, or 20-mg scored tabs; Methylin also available as 2.5-mg, 5-mg, or 10-mg chewable tab and PO solution (5 mg/5 mL and 10 mg/mL) |
| Methylphenidate sustained-release (SR) (Ritalin LA, Metadate CD) | Convert from IR or use 10 mg. | 0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d | 0.6-1 mg/kg/dose PO qd/bid | 10-mg, 20-mg, 30-mg, or 40-mg tabs (Metadate also has 50-mg and 60-mg tabs.); can be sprinkled into soft food (Do not cut, crush, or chew.) |
| Methylphenidate extended release (ER)‡ (Ritalin SR, Methylin ER, Metadate ER, generic SR) | Convert from IR. | 0.2-1.4 mg/kg/dose PO qd/tid; not to exceed 60 mg/d | 0.6-1 mg/kg/dose PO qd/bid | 20-mg Spansules (Do not cut, crush, or chew.) |
| Methylphenidate OROS tablets (Concerta) | Convert from IR or use 18 mg. | 0.3-2 mg/kg PO qd; not to exceed 54 mg/d | 0.8-1.6 mg/kg PO qd | 18-mg, 27-mg, 36-mg, and 54-mg tabs (Do not cut, crush, or chew.) |
| Methylphenidate transdermal patch (Daytrana)† | Convert from IR or use 10 mg (12.5 cm2 patch) released over 9 h and titrate up prn. | 0.3-2 mg/kg released over 9 h; not to exceed one 30-mg patch | 10-30 mg released over 9 h | 10-mg, 15-mg, 20-mg, 30-mg patches, applied to the hip |
| Dexmethylphenidate IR (Focalin) | 2.5-5-mg | 0.1-0.5 mg/kg/dose PO qd to qid; not to exceed 20 mg/d | 0.2-0.3 mg/kg/dose PO bid/tid | 2.5-mg, 5-mg, or 10-mg scored tabs (Do not cut, crush, or chew.) |
| Dexmethylphenidate extended release (Focalin-XR) | 5-10-mg | 0.2-1 mg/kg/dose PO qd to bid; not to exceed 20 mg/d | 0.4-0.6 mg/kg/dose PO qd/bid | 5-mg, 10-mg, or 20-mg scored tabs; can be sprinkled into soft food (Do not cut, crush, or chew.) |
| Dextroamphetamine (Dexedrine, Dextrostat) | 2.5-5 mg | 0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 60 mg/d | 0.3-0.5 mg/kg/dose PO qd/tid | Dexedrine: 5-mg scored tabs; Dextrostat: 5-mg and 10-mg scored tabs |
| Dextroamphetamine Spansules (Dexedrine CR) | 5 mg | 0.1-0.75 mg/kg/dose PO qd/bid; not to exceed 60 mg/d | 0.3-0.6 mg/kg/dose PO qd/bid | 5-mg, 10-mg, or 15-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.) |
| Mixed amphetamine salts IR (Adderall, generic) | 2.5-5 mg | 0.1-0.7 mg/kg/dose PO qd/qid; not to exceed 40 mg/d | 0.3-0.5 mg/kg/dose PO tid/qid | 5-mg, 7.5-mg, 10-mg, 12.5-mg, 15-mg, 20-mg, or 30-mg scored tabs |
| Mixed amphetamine salt XR (Adderall-XR) | Convert from IR or use 5-10 mg | 0.2-1.4 mg/kg/dose PO qd/tid Not to exceed 30 mg/d | 0.6-1 mg/kg/dose PO qd/bid | 5-mg, 10-mg, 15-mg, 20-mg, 25-mg, or 30-mg Spansules; can be sprinkled into soft food (Do not cut, crush, or chew.) |
| Lisdexamfetamine (Vyvanse) | 30 mg PO qam | 30-70 mg PO qam | Data limited (too early to tell) | 20-mg, 30-mg, 40-mg, 50-mg, 60-mg, or 70-mg caps (Swallow cap whole, sprinkle into soft food, or dissolve contents in glass of water and drink immediately.) |
| Note. In general, when the terms methylphenidate, Dexedrine, and Ritalin are used without abbreviations for extended-release preparations (eg, continuous release [CR], SR, osmotic-release oral system [OROS]), a short-acting, IR preparation is implied. * Maximum pediatric dose suggested by the US Food and Drug Administration (FDA). Although some children benefit greatly from doses greater than these, benefit from use of either the lowest and highest ends of the dose range is uncommon. †The methylphenidate patch contains a different total methylphenidate dose than the name implies because it is designed to last 12 hours (eg, 10-mg patch [patch size 12.5 cm2] delivers about 10 mg over 9 h [estimated delivery rate is 1.1 mg/h for this particular patch]). Delivery rate varies depending on patch size. ‡Many patients describe their experience with methylphenidate SR preparations as erratic and uncomfortable. | ||||
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