Evidence-based medication selection for Attention-Deficit/Hyperactivity Disorder
For most patients age 6 and older, stimulant medications (methylphenidate or amphetamines) are first-line treatment with 70-80% response rate. Behavioral therapy is recommended for all ages and is first-line for children under 6.
Non-stimulants (atomoxetine, guanfacine, clonidine) are preferred when patient has tics, substance abuse history, severe anxiety, or if stimulants are ineffective or not tolerated. They are also useful as adjunct therapy.
All patients should have history, physical exam, baseline blood pressure and heart rate before starting stimulants. ECG is mandatory if structural cardiac disease, family history of sudden death, or abnormal cardiac exam. Routine ECG for all patients is controversial.
Stimulants work within 30-60 minutes and effects last 3-12 hours depending on formulation. Non-stimulants (atomoxetine, guanfacine, clonidine) take 4-6 weeks for full therapeutic effect.
The most common side effects are decreased appetite, insomnia, headache, stomachache, and irritability. Most side effects are mild and improve within 1-2 weeks. Monitor growth (height/weight) at every visit in children.
Medication holidays are optional and individualized. Some families skip stimulants on weekends/summers to minimize appetite suppression and allow "catch-up" growth. However, many patients benefit from consistent daily treatment. Non-stimulants should NOT be stopped abruptly (especially alpha-2 agonists).